- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,286.42 / $1,286.42 / $1,286.42
| Facility | | $1,286.42 | $1,286.42 | $1,286.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.42 / $1,351.32 / $2,437.12
| Professional | | $1,286.42 | $1,351.32 | $2,437.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,066.85 / $6,518.84 / $17,378.68
| Facility | | $2,066.85 | $6,518.84 | $17,378.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.83 / $2,180.48 / $2,875.23
| Professional | | $1,374.83 | $2,180.48 | $2,875.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,214.77 / $3,801.92 / $4,896.14
| Facility | | $3,214.77 | $3,801.92 | $4,896.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,120.69 / $2,612.36 / $2,612.36
| Professional | | $2,120.69 | $2,612.36 | $2,612.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,721.98 / $1,721.98 / $2,163.98
| Facility | | $1,721.98 | $1,721.98 | $2,163.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.05 / $1,721.98 / $3,749.63
| Professional | | $1,257.05 | $1,721.98 | $3,749.63 |
- 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
- $2,383.82 / $2,383.82 / $2,503.01
| Professional | | $2,383.82 | $2,383.82 | $2,503.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,717.85 / $2,074.25 / $2,074.25
| Professional | | $1,717.85 | $2,074.25 | $2,074.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,565.67 / $17,378.68 / $17,378.68
| Facility | | $6,565.67 | $17,378.68 | $17,378.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.08 / $1,573.80 / $2,875.23
| Professional | | $1,150.08 | $1,573.80 | $2,875.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,674.38 / $3,674.38 / $3,674.38
| Facility | | $3,674.38 | $3,674.38 | $3,674.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,278.71 / $1,614.72 / $2,755.79
| Professional | | $1,278.71 | $1,614.72 | $2,755.79 |