- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $8,709.64 / $8,709.64
| Facility | | $1,862.09 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,513.56 / $2,344.23
| Professional | | $1,288.25 | $1,513.56 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $5,623.41
| Facility | | $3,162.28 | $3,162.28 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $4,168.69 / $5,128.61
| Professional | | $1,949.84 | $4,168.69 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,137.96 / $2,691.53
| Professional | | $1,862.09 | $2,137.96 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,137.96 / $3,019.95
| Facility | | $1,737.80 | $2,137.96 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,691.53 / $5,128.61
| Facility | | $1,445.44 | $2,691.53 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,137.96 / $2,691.53
| Professional | | $79.43 | $2,137.96 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,754.40 / $7,585.78
| Facility | | $2,884.03 | $5,754.40 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,659.59 / $2,344.23
| Professional | | $1,548.82 | $1,659.59 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $3,090.30
| Facility | | $2,344.23 | $2,344.23 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $2,344.23
| Professional | | $812.83 | $812.83 | $2,344.23 |