- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,244.96 / $1,244.96 / $1,244.96
| Facility | | $1,244.96 | $1,244.96 | $1,244.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.96 / $1,274.42 / $1,944.15
| Professional | | $1,244.96 | $1,274.42 | $1,944.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,525.50 / $4,811.43 / $12,853.25
| Facility | | $1,525.50 | $4,811.43 | $12,853.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.52 / $1,943.80 / $2,782.58
| Professional | | $1,237.52 | $1,943.80 | $2,782.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,024.30 / $3,679.41 / $4,738.39
| Facility | | $3,024.30 | $3,679.41 | $4,738.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.79 / $2,528.17 / $2,528.17
| Professional | | $1,865.79 | $2,528.17 | $2,528.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,648.14 / $1,960.76 / $1,997.56
| Facility | | $1,648.14 | $1,960.76 | $1,997.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.35 / $1,960.76 / $3,513.75
| Professional | | $1,431.35 | $1,960.76 | $3,513.75 |
- 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
- $2,307.00 / $2,307.00 / $2,422.35
| Professional | | $2,307.00 | $2,307.00 | $2,422.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,809.92 / $1,809.92 / $1,809.92
| Professional | | $1,809.92 | $1,809.92 | $1,809.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,153.03 / $12,853.25 / $12,853.25
| Facility | | $6,153.03 | $12,853.25 | $12,853.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.03 / $1,523.10 / $2,782.58
| Professional | | $1,113.03 | $1,523.10 | $2,782.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.73 / $1,523.10 / $2,532.79
| Professional | | $1,177.73 | $1,523.10 | $2,532.79 |