- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,522.63 / $1,522.63 / $1,522.63
| Facility | | $1,522.63 | $1,522.63 | $1,522.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.63 / $1,522.63 / $2,611.84
| Professional | | $1,522.63 | $1,522.63 | $2,611.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,418.72 / $4,474.64 / $19,678.21
| Facility | | $1,418.72 | $4,474.64 | $19,678.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.09 / $2,458.42 / $3,403.20
| Professional | | $1,550.09 | $2,458.42 | $3,403.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,698.83 / $4,500.05 / $5,795.21
| Facility | | $3,698.83 | $4,500.05 | $5,795.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,281.92 / $3,092.05 / $3,092.05
| Professional | | $2,281.92 | $3,092.05 | $3,092.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,015.73 / $2,479.82 / $2,479.82
| Facility | | $2,015.73 | $2,479.82 | $2,479.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.27 / $2,479.82 / $4,444.13
| Professional | | $1,810.27 | $2,479.82 | $4,444.13 |
- 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
- $2,821.55 / $2,821.55 / $2,962.63
| Professional | | $2,821.55 | $2,821.55 | $2,962.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,974.04 / $1,974.04 / $1,974.04
| Professional | | $1,974.04 | $1,974.04 | $1,974.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,781.90 / $19,678.21 / $19,678.21
| Facility | | $7,781.90 | $19,678.21 | $19,678.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.28 / $1,862.79 / $3,403.20
| Professional | | $1,361.28 | $1,862.79 | $3,403.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,569.77 / $2,388.64 / $3,097.69
| Professional | | $1,569.77 | $2,388.64 | $3,097.69 |