- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,088.28 / $1,088.28 / $1,088.28
| Facility | | $1,088.28 | $1,088.28 | $1,088.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,088.28 / $1,147.80 / $1,799.70
| Professional | | $1,088.28 | $1,147.80 | $1,799.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,322.10 / $4,169.89 / $11,750.92
| Facility | | $1,322.10 | $4,169.89 | $11,750.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.77 / $1,788.64 / $2,432.39
| Professional | | $1,127.77 | $1,788.64 | $2,432.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,643.70 / $3,216.36 / $4,142.07
| Facility | | $2,643.70 | $3,216.36 | $4,142.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.97 / $2,210.01 / $2,210.01
| Professional | | $1,630.97 | $2,210.01 | $2,210.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.71 / $1,747.16 / $1,747.16
| Facility | | $1,440.71 | $1,747.16 | $1,747.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.43 / $1,747.16 / $3,131.25
| Professional | | $1,275.43 | $1,747.16 | $3,131.25 |
- 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
- $2,016.67 / $2,016.67 / $2,117.50
| Professional | | $2,016.67 | $2,016.67 | $2,117.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,693.79 / $1,693.79 / $1,693.79
| Professional | | $1,693.79 | $1,693.79 | $1,693.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,482.73 / $11,750.92 / $11,750.92
| Facility | | $5,482.73 | $11,750.92 | $11,750.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.96 / $1,331.41 / $2,432.39
| Professional | | $972.96 | $1,331.41 | $2,432.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.77 / $1,331.41 / $2,260.57
| Professional | | $1,081.77 | $1,331.41 | $2,260.57 |