- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,691.53 / $5,011.87
| Professional | | $2,238.72 | $2,691.53 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,011.87 / $26,302.68
| Facility | | $4,786.30 | $5,011.87 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,890.45 / $5,128.61
| Professional | | $2,290.87 | $3,890.45 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $380.19 / $1,148.15
| Facility | | $380.19 | $380.19 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,466.84 / $4,466.84
| Professional | | $3,981.07 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $3,311.31
| Professional | | $2,398.83 | $2,398.83 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $4,897.79 / $9,772.37
| Facility | | $83.18 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $6,760.83
| Professional | | $4,466.84 | $4,466.84 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,011.87 / $26,302.68
| Facility | | $4,786.30 | $5,011.87 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,981.07 / $5,128.61
| Professional | | $2,344.23 | $3,981.07 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.63 / $3,388.44 / $6,165.95
| Facility | | $3.63 | $3,388.44 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,467.37 / $4,466.84
| Professional | | $2,238.72 | $3,467.37 | $4,466.84 |