- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,577.95 / $10,162.29 / $11,192.10
| Facility | | $3,577.95 | $10,162.29 | $11,192.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.27 / $2,167.96 / $2,303.46
| Professional | | $1,436.27 | $2,167.96 | $2,303.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.76 / $2,113.76 / $2,113.76
| Professional | | $2,113.76 | $2,113.76 | $2,113.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,814.31 / $3,520.83 / $8,097.48
| Facility | | $1,814.31 | $3,520.83 | $8,097.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,061.96 / $13,061.96 / $13,061.96
| Professional | | $13,061.96 | $13,061.96 | $13,061.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,845.45 / $3,658.43 / $6,693.58
| Professional | | $2,845.45 | $3,658.43 | $6,693.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,170.60 / $11,192.10 / $11,192.10
| Facility | | $4,170.60 | $11,192.10 | $11,192.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.54 / $2,303.46 / $11,192.10
| Professional | | $1,778.54 | $2,303.46 | $11,192.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,010.73 / $4,064.93 / $5,419.90
| Professional | | $4,010.73 | $4,064.93 | $5,419.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,888.30 / $3,424.34 / $8,992.73
| Facility | | $1,888.30 | $3,424.34 | $8,992.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,061.96 / $13,061.96 / $13,061.96
| Professional | | $13,061.96 | $13,061.96 | $13,061.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,709.95 / $2,709.95 / $2,980.95
| Facility | | $2,709.95 | $2,709.95 | $2,980.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,709.95 / $2,709.95 / $2,980.95
| Professional | | $2,709.95 | $2,709.95 | $2,980.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.18 / $1,625.97 / $4,064.93
| Professional | | $1,138.18 | $1,625.97 | $4,064.93 |