- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,043.83 / $1,043.83 / $1,043.83
| Facility | | $1,043.83 | $1,043.83 | $1,043.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.83 / $1,100.92 / $1,901.04
| Professional | | $1,043.83 | $1,100.92 | $1,901.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,864.61 / $5,565.86 / $11,410.07
| Facility | | $1,864.61 | $5,565.86 | $11,410.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.86 / $1,795.38 / $2,333.04
| Professional | | $1,090.86 | $1,795.38 | $2,333.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,608.55 / $3,084.98 / $3,972.88
| Facility | | $2,608.55 | $3,084.98 | $3,972.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,759.47 / $2,119.73 / $2,119.73
| Professional | | $1,759.47 | $2,119.73 | $2,119.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,366.32 / $1,366.32 / $1,366.32
| Facility | | $1,366.32 | $1,366.32 | $1,366.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.41 / $1,366.32 / $2,837.63
| Professional | | $997.41 | $1,366.32 | $2,837.63 |
- 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
- $1,934.30 / $1,934.30 / $2,031.02
| Professional | | $1,934.30 | $1,934.30 | $2,031.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,541.51 / $1,541.51 / $1,541.51
| Professional | | $1,541.51 | $1,541.51 | $1,541.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,968.81 / $11,410.07 / $11,410.07
| Facility | | $4,968.81 | $11,410.07 | $11,410.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.22 / $1,436.30 / $2,333.04
| Professional | | $933.22 | $1,436.30 | $2,333.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.46 / $1,436.30 / $2,333.04
| Professional | | $987.46 | $1,436.30 | $2,333.04 |