- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,488.38 / $1,488.38 / $1,488.38
| Facility | | $1,488.38 | $1,488.38 | $1,488.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,488.38 / $1,720.20 / $2,007.67
| Professional | | $1,488.38 | $1,720.20 | $2,007.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,436.70 / $10,582.60 / $20,114.68
| Facility | | $6,436.70 | $10,582.60 | $20,114.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,782.67 / $4,322.76 / $6,065.36
| Professional | | $2,782.67 | $4,322.76 | $6,065.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,936.74 / $5,582.79 / $13,430.15
| Facility | | $3,936.74 | $5,582.79 | $13,430.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,173.99 / $5,382.51 / $7,614.83
| Professional | | $3,173.99 | $5,382.51 | $7,614.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,200.29 / $5,104.01 / $10,574.93
| Facility | | $3,200.29 | $5,104.01 | $10,574.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,794.40 / $4,782.05 / $6,337.23
| Professional | | $2,794.40 | $4,782.05 | $6,337.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,128.92 / $3,053.00 / $4,018.72
| Facility | | $2,128.92 | $3,053.00 | $4,018.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,182.71 / $4,461.60 / $9,593.98
| Professional | | $2,182.71 | $4,461.60 | $9,593.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $3,500.00 / $8,152.00
| Facility | | $1,751.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,205.21 / $4,480.93 / $6,879.22
| Professional | | $2,205.21 | $4,480.93 | $6,879.22 |