- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,591.40 / $1,591.40 / $1,591.40
| Facility | | $1,591.40 | $1,591.40 | $1,591.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,591.40 / $1,727.27 / $3,207.39
| Professional | | $1,591.40 | $1,727.27 | $3,207.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,881.45 / $5,934.09 / $23,067.66
| Facility | | $1,881.45 | $5,934.09 | $23,067.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.45 / $2,800.07 / $3,556.90
| Professional | | $1,778.45 | $2,800.07 | $3,556.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,865.88 / $4,703.29 / $6,056.95
| Facility | | $3,865.88 | $4,703.29 | $6,056.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,384.98 / $3,231.70 / $3,231.70
| Professional | | $2,384.98 | $3,231.70 | $3,231.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,106.75 / $2,677.01 / $3,141.52
| Facility | | $2,106.75 | $2,677.01 | $3,141.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.31 / $3,141.52 / $5,629.88
| Professional | | $2,293.31 | $3,141.52 | $5,629.88 |
- 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
- $2,948.98 / $2,948.98 / $3,096.43
| Professional | | $2,948.98 | $2,948.98 | $3,096.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,453.05 / $2,453.05 / $2,453.05
| Professional | | $2,453.05 | $2,453.05 | $2,453.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,858.39 / $23,067.66 / $23,067.66
| Facility | | $9,858.39 | $23,067.66 | $23,067.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,505.45 / $1,946.92 / $3,556.90
| Professional | | $1,505.45 | $1,946.92 | $3,556.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,581.87 / $2,080.06 / $3,875.41
| Professional | | $1,581.87 | $2,080.06 | $3,875.41 |