- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,287.43 / $1,287.43 / $1,287.43
| Facility | | $1,287.43 | $1,287.43 | $1,287.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.43 / $1,357.84 / $2,344.69
| Professional | | $1,287.43 | $1,357.84 | $2,344.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,636.31 / $7,869.39 / $14,058.21
| Facility | | $2,636.31 | $7,869.39 | $14,058.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.45 / $2,188.87 / $2,877.50
| Professional | | $1,345.45 | $2,188.87 | $2,877.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,217.31 / $3,804.93 / $4,900.03
| Facility | | $3,217.31 | $3,804.93 | $4,900.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,929.43 / $2,614.42 / $2,614.42
| Professional | | $1,929.43 | $2,614.42 | $2,614.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,952.91 / $1,952.91 / $2,165.69
| Facility | | $1,952.91 | $1,952.91 | $2,165.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.62 / $1,952.91 / $3,499.88
| Professional | | $1,425.62 | $1,952.91 | $3,499.88 |
- 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
- $2,385.69 / $2,385.69 / $2,504.98
| Professional | | $2,385.69 | $2,385.69 | $2,504.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,151.09 / $2,151.09 / $2,151.09
| Professional | | $2,151.09 | $2,151.09 | $2,151.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,128.43 / $14,058.21 / $14,058.21
| Facility | | $6,128.43 | $14,058.21 | $14,058.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.00 / $1,575.05 / $2,877.50
| Professional | | $1,151.00 | $1,575.05 | $2,877.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,279.73 / $1,745.45 / $2,877.50
| Professional | | $1,279.73 | $1,745.45 | $2,877.50 |