- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,023.29 / $2,041.74
| Professional | | $758.58 | $1,023.29 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,778.28 / $10,964.78
| Facility | | $1,548.82 | $1,778.28 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,318.26 / $1,778.28
| Professional | | $812.83 | $1,318.26 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,238.72 / $2,951.21
| Facility | | $1,862.09 | $2,238.72 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $1,513.56
| Professional | | $1,122.02 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $1,479.11
| Facility | | $1,000.00 | $1,258.93 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,479.11
| Professional | | $1,071.52 | $1,071.52 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $4,897.79 / $9,772.37
| Facility | | $83.18 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $2,290.87
| Professional | | $1,513.56 | $1,513.56 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Professional | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,778.28 / $10,964.78
| Facility | | $1,548.82 | $1,778.28 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,318.26 / $2,238.72
| Professional | | $831.76 | $1,318.26 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.38 / $1,288.25 / $2,344.23
| Facility | | $1.38 | $1,288.25 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,230.27 / $1,513.56
| Professional | | $741.31 | $1,230.27 | $1,513.56 |