- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,417.70 / $1,417.70 / $1,417.70
| Facility | | $1,417.70 | $1,417.70 | $1,417.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.08 / $1,417.70 / $1,826.99
| Professional | | $1,302.08 | $1,417.70 | $1,826.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,891.62 / $5,142.70 / $14,508.26
| Facility | | $1,891.62 | $5,142.70 | $14,508.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.73 / $1,986.20 / $3,168.65
| Professional | | $1,188.73 | $1,986.20 | $3,168.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,443.91 / $4,189.91 / $5,395.81
| Facility | | $3,443.91 | $4,189.91 | $5,395.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,124.66 / $2,501.39 / $2,501.39
| Professional | | $2,124.66 | $2,501.39 | $2,501.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,638.80 / $1,876.79 / $2,274.71
| Facility | | $1,638.80 | $1,876.79 | $2,274.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.32 / $1,196.32 / $2,937.00
| Professional | | $1,196.32 | $1,196.32 | $2,937.00 |
- 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
- $2,627.09 / $2,627.09 / $2,758.44
| Professional | | $2,627.09 | $2,627.09 | $2,758.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.46 / $1,554.46 / $1,554.46
| Professional | | $1,554.46 | $1,554.46 | $1,554.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,142.70 / $14,508.26 / $14,508.26
| Facility | | $5,142.70 | $14,508.26 | $14,508.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.16 / $1,618.75 / $3,168.65
| Professional | | $1,079.16 | $1,618.75 | $3,168.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.94 / $1,011.72 / $1,347.84
| Facility | | $1.94 | $1,011.72 | $1,347.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.16 / $1,618.75 / $2,627.09
| Professional | | $1,079.16 | $1,618.75 | $2,627.09 |