- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,297.34 / $1,297.34 / $1,297.34
| Facility | | $1,297.34 | $1,297.34 | $1,297.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.34 / $1,297.34 / $2,088.88
| Professional | | $1,297.34 | $1,297.34 | $2,088.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,372.95 / $4,330.28 / $13,970.56
| Facility | | $1,372.95 | $4,330.28 | $13,970.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,261.45 / $1,983.98 / $2,899.66
| Professional | | $1,261.45 | $1,983.98 | $2,899.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,151.56 / $3,834.23 / $4,937.76
| Facility | | $3,151.56 | $3,834.23 | $4,937.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,944.30 / $2,634.55 / $2,634.55
| Professional | | $1,944.30 | $2,634.55 | $2,634.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,552.76 / $1,717.48 / $2,081.62
| Facility | | $1,552.76 | $1,717.48 | $2,081.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.51 / $1,133.51 / $3,519.75
| Professional | | $1,133.51 | $1,133.51 | $3,519.75 |
- 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
- $2,404.08 / $2,404.08 / $2,524.28
| Professional | | $2,404.08 | $2,404.08 | $2,524.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,578.77 / $1,578.77 / $1,578.77
| Professional | | $1,578.77 | $1,578.77 | $1,578.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,163.49 / $13,970.56 / $13,970.56
| Facility | | $6,163.49 | $13,970.56 | $13,970.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.85 / $1,587.18 / $2,899.66
| Professional | | $1,159.85 | $1,587.18 | $2,899.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.85 / $1,587.18 / $2,494.23
| Professional | | $1,159.85 | $1,587.18 | $2,494.23 |