- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,180.88 / $1,180.88 / $1,180.88
| Facility | | $1,180.88 | $1,180.88 | $1,180.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.88 / $1,264.61 / $2,376.32
| Professional | | $1,180.88 | $1,264.61 | $2,376.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,418.11 / $7,218.06 / $16,970.52
| Facility | | $2,418.11 | $7,218.06 | $16,970.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.67 / $2,059.96 / $2,639.34
| Professional | | $1,319.67 | $2,059.96 | $2,639.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.04 / $3,490.02 / $4,494.49
| Facility | | $2,951.04 | $3,490.02 | $4,494.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,769.75 / $2,398.05 / $2,398.05
| Professional | | $1,769.75 | $2,398.05 | $2,398.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.76 / $2,283.76 / $2,283.76
| Facility | | $2,283.76 | $2,283.76 | $2,283.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.14 / $2,283.76 / $3,804.00
| Professional | | $1,667.14 | $2,283.76 | $3,804.00 |
- 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
- $2,188.25 / $2,188.25 / $2,297.66
| Professional | | $2,188.25 | $2,188.25 | $2,297.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,959.29 / $1,959.29 / $1,959.29
| Professional | | $1,959.29 | $1,959.29 | $1,959.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,660.73 / $16,970.52 / $16,970.52
| Facility | | $6,660.73 | $16,970.52 | $16,970.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,114.00 / $1,506.82 / $2,639.34
| Professional | | $1,114.00 | $1,506.82 | $2,639.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.99 / $1,444.70 / $2,639.34
| Professional | | $1,029.99 | $1,444.70 | $2,639.34 |