- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,243.53 / $1,243.53 / $1,243.53
| Facility | | $1,243.53 | $1,243.53 | $1,243.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.53 / $1,243.53 / $2,038.69
| Professional | | $1,243.53 | $1,243.53 | $2,038.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.25 / $4,009.52 / $14,693.79
| Facility | | $1,271.25 | $4,009.52 | $14,693.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.14 / $1,918.95 / $2,779.38
| Professional | | $1,231.14 | $1,918.95 | $2,779.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,020.82 / $3,675.18 / $4,732.93
| Facility | | $3,020.82 | $3,675.18 | $4,732.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,863.66 / $2,525.27 / $2,525.27
| Professional | | $1,863.66 | $2,525.27 | $2,525.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,646.24 / $1,769.38 / $1,995.28
| Facility | | $1,646.24 | $1,769.38 | $1,995.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.65 / $1,769.38 / $3,171.00
| Professional | | $1,291.65 | $1,769.38 | $3,171.00 |
- 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
- $2,304.35 / $2,304.35 / $2,419.57
| Professional | | $2,304.35 | $2,304.35 | $2,419.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.84 / $1,540.84 / $1,540.84
| Professional | | $1,540.84 | $1,540.84 | $1,540.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,552.50 / $14,693.79 / $14,693.79
| Facility | | $5,552.50 | $14,693.79 | $14,693.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.75 / $1,521.35 / $2,779.38
| Professional | | $1,111.75 | $1,521.35 | $2,779.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,209.93 / $1,521.35 / $2,745.58
| Professional | | $1,209.93 | $1,521.35 | $2,745.58 |