- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,444.75 / $1,444.75 / $1,444.75
| Facility | | $1,444.75 | $1,444.75 | $1,444.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,444.75 / $1,534.77 / $2,883.94
| Professional | | $1,444.75 | $1,534.77 | $2,883.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,665.00 / $5,251.41 / $20,412.75
| Facility | | $1,665.00 | $5,251.41 | $20,412.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.95 / $2,477.80 / $3,229.10
| Professional | | $1,607.95 | $2,477.80 | $3,229.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,610.43 / $4,269.84 / $5,498.75
| Facility | | $3,610.43 | $4,269.84 | $5,498.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,381.71 / $2,933.87 / $2,933.87
| Professional | | $2,381.71 | $2,933.87 | $2,933.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,912.60 / $2,430.32 / $2,561.34
| Facility | | $1,912.60 | $2,430.32 | $2,561.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.78 / $2,561.34 / $4,503.75
| Professional | | $1,869.78 | $2,561.34 | $4,503.75 |
- 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
- $2,677.20 / $2,677.20 / $2,811.06
| Professional | | $2,677.20 | $2,677.20 | $2,811.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,268.16 / $2,268.16 / $2,268.16
| Professional | | $2,268.16 | $2,268.16 | $2,268.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,886.61 / $20,412.75 / $20,412.75
| Facility | | $7,886.61 | $20,412.75 | $20,412.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,339.96 / $1,833.75 / $3,229.10
| Professional | | $1,339.96 | $1,833.75 | $3,229.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.64 / $1,888.36 / $3,229.10
| Professional | | $1,291.64 | $1,888.36 | $3,229.10 |