- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,778.28 / $3,467.37
| Professional | | $1,513.56 | $1,778.28 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,715.35 / $17,782.79
| Facility | | $3,630.78 | $3,715.35 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,630.27 / $3,890.45
| Professional | | $1,621.81 | $2,630.27 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,011.87 / $6,606.93
| Facility | | $4,265.80 | $5,011.87 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,467.37 / $3,467.37
| Professional | | $2,511.89 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,884.03 / $2,884.03
| Facility | | $1,819.70 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,884.03
| Professional | | $2,454.71 | $2,454.71 | $2,884.03 |
- 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
- $3,311.31 / $3,311.31 / $5,011.87
| Professional | | $3,311.31 | $3,311.31 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,715.35 / $17,782.79
| Facility | | $3,630.78 | $3,715.35 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,754.23 / $4,265.80
| Professional | | $1,659.59 | $2,754.23 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.45 / $1,949.84 / $4,365.16
| Facility | | $2.45 | $1,949.84 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,398.83 / $3,311.31
| Professional | | $1,513.56 | $2,398.83 | $3,311.31 |