- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.85 / $1,216.85 / $1,216.85
| Facility | | $1,216.85 | $1,216.85 | $1,216.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.85 / $1,245.89 / $2,341.13
| Professional | | $1,216.85 | $1,245.89 | $2,341.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,257.00 / $3,964.58 / $17,638.56
| Facility | | $1,257.00 | $3,964.58 | $17,638.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.00 / $2,141.06 / $2,719.76
| Professional | | $1,257.00 | $2,141.06 | $2,719.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,956.02 / $3,596.34 / $4,631.41
| Facility | | $2,956.02 | $3,596.34 | $4,631.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.03 / $2,471.10 / $2,471.10
| Professional | | $2,006.03 | $2,471.10 | $2,471.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,610.92 / $2,046.97 / $2,125.02
| Facility | | $1,610.92 | $2,046.97 | $2,125.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.26 / $2,125.02 / $3,808.13
| Professional | | $1,551.26 | $2,125.02 | $3,808.13 |
- 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
- $2,254.92 / $2,254.92 / $2,367.67
| Professional | | $2,254.92 | $2,254.92 | $2,367.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,769.42 / $1,769.42 / $1,769.42
| Professional | | $1,769.42 | $1,769.42 | $1,769.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,668.49 / $17,638.56 / $17,638.56
| Facility | | $6,668.49 | $17,638.56 | $17,638.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.13 / $1,501.88 / $2,719.76
| Professional | | $1,151.13 | $1,501.88 | $2,719.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.13 / $1,565.99 / $3,136.32
| Professional | | $1,151.13 | $1,565.99 | $3,136.32 |