- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,697.59 / $1,697.59 / $1,697.59
| Facility | | $1,697.59 | $1,697.59 | $1,697.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.20 / $1,697.59 / $1,939.13
| Professional | | $1,050.20 | $1,697.59 | $1,939.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,092.91 / $2,443.17 / $3,402.08
| Facility | | $2,092.91 | $2,443.17 | $3,402.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.54 / $2,321.02 / $2,443.17
| Professional | | $1,954.54 | $2,321.02 | $2,443.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,499.97 / $7,538.77 / $20,938.28
| Facility | | $1,499.97 | $7,538.77 | $20,938.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,832.38 / $3,002.32 / $3,597.12
| Professional | | $2,832.38 | $3,002.32 | $3,597.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,475.68 / $7,233.08 / $16,486.84
| Facility | | $4,475.68 | $7,233.08 | $16,486.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,832.38 / $2,832.38 / $2,914.80
| Professional | | $2,832.38 | $2,832.38 | $2,914.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.76 / $2,443.17 / $12,090.55
| Facility | | $758.76 | $2,443.17 | $12,090.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.72 / $1,218.88 / $2,663.65
| Professional | | $760.72 | $1,218.88 | $2,663.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.72 / $1,218.88 / $2,687.50
| Professional | | $760.72 | $1,218.88 | $2,687.50 |