- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,428.71 / $1,428.71 / $1,428.71
| Facility | | $1,428.71 | $1,428.71 | $1,428.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.71 / $1,428.71 / $2,167.19
| Professional | | $1,428.71 | $1,428.71 | $2,167.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,948.00 / $6,143.99 / $15,180.10
| Facility | | $1,948.00 | $6,143.99 | $15,180.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,398.28 / $2,184.86 / $3,193.27
| Professional | | $1,398.28 | $2,184.86 | $3,193.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,470.67 / $4,222.47 / $5,437.74
| Facility | | $3,470.67 | $4,222.47 | $5,437.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,355.28 / $2,901.32 / $2,901.32
| Professional | | $2,355.28 | $2,901.32 | $2,901.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,891.37 / $2,084.13 / $2,292.38
| Facility | | $1,891.37 | $2,084.13 | $2,292.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,521.41 / $2,084.13 / $3,834.75
| Professional | | $1,521.41 | $2,084.13 | $3,834.75 |
- 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
- $2,647.50 / $2,647.50 / $2,779.88
| Professional | | $2,647.50 | $2,647.50 | $2,779.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.98 / $1,830.98 / $1,830.98
| Professional | | $1,830.98 | $1,830.98 | $1,830.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,714.92 / $15,180.10 / $15,180.10
| Facility | | $6,714.92 | $15,180.10 | $15,180.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.31 / $1,747.89 / $3,193.27
| Professional | | $1,277.31 | $1,747.89 | $3,193.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.19 / $1,815.91 / $2,070.48
| Facility | | $2.19 | $1,815.91 | $2,070.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,351.55 / $1,747.89 / $2,936.08
| Professional | | $1,351.55 | $1,747.89 | $2,936.08 |