- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,951.72 / $1,951.72 / $1,951.72
| Facility | | $1,951.72 | $1,951.72 | $1,951.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,951.72 / $1,951.72 / $2,301.28
| Professional | | $1,951.72 | $1,951.72 | $2,301.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,689.88 / $2,958.86 / $2,988.75
| Professional | | $2,689.88 | $2,958.86 | $2,988.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,787.17 / $3,366.53 / $3,366.53
| Facility | | $1,787.17 | $3,366.53 | $3,366.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,274.80 / $3,724.50 / $5,191.25
| Professional | | $3,274.80 | $3,724.50 | $5,191.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,609.55 / $3,317.92 / $13,048.73
| Facility | | $1,609.55 | $3,317.92 | $13,048.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.20 / $1,629.79 / $2,544.73
| Professional | | $1,165.20 | $1,629.79 | $2,544.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,356.67 / $3,366.53 / $4,241.68
| Facility | | $3,356.67 | $3,366.53 | $4,241.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,757.22 / $3,932.56 / $6,935.58
| Professional | | $2,757.22 | $3,932.56 | $6,935.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.21 / $1,448.21 / $1,448.21
| Facility | | $1,448.21 | $1,448.21 | $1,448.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,106.94 / $1,615.26 / $2,544.73
| Professional | | $1,106.94 | $1,615.26 | $2,544.73 |