- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,383.32 / $1,383.32 / $1,383.32
| Facility | | $1,383.32 | $1,383.32 | $1,383.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.32 / $1,427.06 / $2,440.09
| Professional | | $1,383.32 | $1,427.06 | $2,440.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,286.51 / $4,057.65 / $16,880.98
| Facility | | $1,286.51 | $4,057.65 | $16,880.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.15 / $2,282.92 / $3,091.84
| Professional | | $1,426.15 | $2,282.92 | $3,091.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,360.42 / $4,088.33 / $5,265.00
| Facility | | $3,360.42 | $4,088.33 | $5,265.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,280.46 / $2,809.16 / $2,809.16
| Professional | | $2,280.46 | $2,809.16 | $2,809.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.89 / $1,831.30 / $2,219.56
| Facility | | $1,819.89 | $1,831.30 | $2,219.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.52 / $1,819.89 / $4,039.50
| Professional | | $1,328.52 | $1,819.89 | $4,039.50 |
- 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
- $2,563.40 / $2,563.40 / $2,691.57
| Professional | | $2,563.40 | $2,563.40 | $2,691.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,850.39 / $1,850.39 / $1,850.39
| Professional | | $1,850.39 | $1,850.39 | $1,850.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,073.05 / $16,880.98 / $16,880.98
| Facility | | $7,073.05 | $16,880.98 | $16,880.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,236.74 / $1,692.37 / $3,091.84
| Professional | | $1,236.74 | $1,692.37 | $3,091.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,776.27 / $1,776.27 / $1,776.27
| Facility | | $1,776.27 | $1,776.27 | $1,776.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.05 / $1,692.37 / $3,091.84
| Professional | | $1,375.05 | $1,692.37 | $3,091.84 |