- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,210.83 / $1,210.83 / $1,210.83
| Facility | | $1,210.83 | $1,210.83 | $1,210.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,210.83 / $1,277.07 / $2,205.19
| Professional | | $1,210.83 | $1,277.07 | $2,205.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,162.92 / $6,456.32 / $13,221.84
| Facility | | $2,162.92 | $6,456.32 | $13,221.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.41 / $2,082.62 / $2,706.29
| Professional | | $1,265.41 | $2,082.62 | $2,706.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,025.89 / $3,578.54 / $4,608.49
| Facility | | $3,025.89 | $3,578.54 | $4,608.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,245.07 / $2,458.88 / $2,458.88
| Professional | | $2,245.07 | $2,458.88 | $2,458.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.92 / $1,584.92 / $1,584.92
| Facility | | $1,584.92 | $1,584.92 | $1,584.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.99 / $1,584.92 / $3,291.75
| Professional | | $1,156.99 | $1,584.92 | $3,291.75 |
- 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
- $2,243.76 / $2,243.76 / $2,355.94
| Professional | | $2,243.76 | $2,243.76 | $2,355.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.88 / $1,787.88 / $1,787.88
| Professional | | $1,787.88 | $1,787.88 | $1,787.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,763.90 / $13,221.84 / $13,221.84
| Facility | | $5,763.90 | $13,221.84 | $13,221.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.52 / $1,666.10 / $2,706.29
| Professional | | $1,082.52 | $1,666.10 | $2,706.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.32 / $1,666.10 / $2,771.24
| Professional | | $1,248.32 | $1,666.10 | $2,771.24 |