- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,260.99 / $1,260.99 / $1,260.99
| Facility | | $1,260.99 | $1,260.99 | $1,260.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.75 / $1,260.99 / $1,625.04
| Professional | | $1,255.75 | $1,260.99 | $1,625.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,454.31 / $4,818.13 / $14,485.79
| Facility | | $1,454.31 | $4,818.13 | $14,485.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.27 / $1,809.74 / $2,818.39
| Professional | | $1,117.27 | $1,809.74 | $2,818.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,063.22 / $3,726.76 / $4,799.37
| Facility | | $3,063.22 | $3,726.76 | $4,799.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,078.79 / $2,224.89 / $2,224.89
| Professional | | $2,078.79 | $2,224.89 | $2,224.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,499.97 / $1,669.35 / $2,023.27
| Facility | | $1,499.97 | $1,669.35 | $2,023.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.98 / $1,499.97 / $2,832.38
| Professional | | $1,094.98 | $1,499.97 | $2,832.38 |
- 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
- $2,336.69 / $2,336.69 / $2,453.52
| Professional | | $2,336.69 | $2,336.69 | $2,453.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.16 / $1,453.16 / $1,453.16
| Professional | | $1,453.16 | $1,453.16 | $1,453.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,177.72 / $14,485.79 / $14,485.79
| Facility | | $5,177.72 | $14,485.79 | $14,485.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $959.87 / $1,439.81 / $2,818.39
| Professional | | $959.87 | $1,439.81 | $2,818.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.10 / $1,439.81 / $2,417.90
| Professional | | $967.10 | $1,439.81 | $2,417.90 |