- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,348.96 / $1,380.38
| Professional | | $1,288.25 | $1,348.96 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $125.89 / $1,621.81
| Professional | | $125.89 | $125.89 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $3,090.30
| Facility | | $1,548.82 | $1,548.82 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Professional | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $234.42 / $8,511.38
| Facility | | $134.90 | $234.42 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $194.98 / $275.42
| Professional | | $141.25 | $194.98 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,698.24 / $3,019.95
| Professional | | $1,174.90 | $1,698.24 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $125.89 / $1,621.81
| Professional | | $125.89 | $125.89 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,041.74 / $2,630.27
| Facility | | $1,348.96 | $2,041.74 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,348.96 / $2,818.38
| Professional | | $125.89 | $1,348.96 | $2,818.38 |