- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,110.55 / $1,110.55 / $1,110.55
| Facility | | $1,110.55 | $1,110.55 | $1,110.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,110.55 / $1,131.85 / $1,941.80
| Professional | | $1,110.55 | $1,131.85 | $1,941.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,220.40 / $3,849.14 / $12,160.93
| Facility | | $1,220.40 | $3,849.14 | $12,160.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.43 / $1,827.75 / $2,482.17
| Professional | | $1,152.43 | $1,827.75 | $2,482.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,697.79 / $3,282.18 / $4,226.82
| Facility | | $2,697.79 | $3,282.18 | $4,226.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.77 / $2,255.23 / $2,255.23
| Professional | | $1,830.77 | $2,255.23 | $2,255.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,470.18 / $1,868.14 / $1,964.43
| Facility | | $1,470.18 | $1,868.14 | $1,964.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.03 / $1,964.43 / $3,520.50
| Professional | | $1,434.03 | $1,964.43 | $3,520.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $4,618.00 / $9,239.00
| Facility | | $83.43 | $4,618.00 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,057.92 / $2,057.92 / $2,160.83
| Professional | | $2,057.92 | $2,057.92 | $2,160.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.57 / $1,756.57 / $1,756.57
| Professional | | $1,756.57 | $1,756.57 | $1,756.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,164.56 / $12,160.93 / $12,160.93
| Facility | | $6,164.56 | $12,160.93 | $12,160.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $992.87 / $1,358.65 / $2,482.17
| Professional | | $992.87 | $1,358.65 | $2,482.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.90 / $1,417.07 / $2,482.17
| Professional | | $1,103.90 | $1,417.07 | $2,482.17 |