- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,239.83 / $1,239.83 / $1,239.83
| Facility | | $1,239.83 | $1,239.83 | $1,239.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.83 / $1,239.83 / $1,970.76
| Professional | | $1,239.83 | $1,239.83 | $1,970.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,538.85 / $7,578.47 / $13,723.75
| Facility | | $2,538.85 | $7,578.47 | $13,723.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.58 / $2,046.11 / $2,771.12
| Professional | | $1,252.58 | $2,046.11 | $2,771.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,098.37 / $3,664.26 / $4,718.87
| Facility | | $3,098.37 | $3,664.26 | $4,718.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,858.11 / $2,517.76 / $2,517.76
| Professional | | $1,858.11 | $2,517.76 | $2,517.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,119.51 / $2,119.51 / $2,119.51
| Facility | | $2,119.51 | $2,119.51 | $2,119.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.24 / $2,119.51 / $3,530.63
| Professional | | $1,547.24 | $2,119.51 | $3,530.63 |
- 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
- $2,297.51 / $2,297.51 / $2,412.39
| Professional | | $2,297.51 | $2,297.51 | $2,412.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,945.75 / $1,945.75 / $1,945.75
| Professional | | $1,945.75 | $1,945.75 | $1,945.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,182.59 / $13,723.75 / $13,723.75
| Facility | | $6,182.59 | $13,723.75 | $13,723.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.45 / $1,516.82 / $2,771.12
| Professional | | $1,108.45 | $1,516.82 | $2,771.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.58 / $1,680.93 / $2,771.12
| Professional | | $1,252.58 | $1,680.93 | $2,771.12 |