- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $6,165.95 / $9,332.54
| Facility | | $3,019.95 | $6,165.95 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,862.09 / $2,089.30
| Professional | | $1,380.38 | $1,862.09 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Professional | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,630.78 / $7,762.47
| Facility | | $2,238.72 | $3,630.78 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,964.78 / $10,964.78 / $10,964.78
| Professional | | $10,964.78 | $10,964.78 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,090.30 / $4,897.79
| Professional | | $2,398.83 | $3,090.30 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,754.23 / $4,265.80
| Professional | | $1,698.24 | $2,754.23 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,754.40 / $9,332.54
| Facility | | $3,090.30 | $5,754.40 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,862.09 / $8,128.31
| Professional | | $1,380.38 | $1,862.09 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Professional | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,511.89
| Facility | | $2,290.87 | $2,290.87 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,511.89
| Professional | | $2,290.87 | $2,290.87 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,754.23
| Facility | | $2,290.87 | $2,290.87 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,380.38 / $2,818.38
| Professional | | $954.99 | $1,380.38 | $2,818.38 |