- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,073.75 / $1,073.75 / $1,073.75
| Facility | | $1,073.75 | $1,073.75 | $1,073.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.75 / $1,073.75 / $1,792.15
| Professional | | $1,073.75 | $1,073.75 | $1,792.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,372.95 / $4,330.28 / $13,221.44
| Facility | | $1,372.95 | $4,330.28 | $13,221.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.74 / $1,651.78 / $2,399.92
| Professional | | $1,059.74 | $1,651.78 | $2,399.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,608.39 / $3,173.41 / $4,086.75
| Facility | | $2,608.39 | $3,173.41 | $4,086.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.21 / $2,180.48 / $2,180.48
| Professional | | $1,609.21 | $2,180.48 | $2,180.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,421.48 / $1,620.00 / $1,722.85
| Facility | | $1,421.48 | $1,620.00 | $1,722.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.59 / $1,620.00 / $2,903.25
| Professional | | $1,182.59 | $1,620.00 | $2,903.25 |
- 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
- $1,989.74 / $1,989.74 / $2,089.23
| Professional | | $1,989.74 | $1,989.74 | $2,089.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,354.49 / $1,354.49 / $1,354.49
| Professional | | $1,354.49 | $1,354.49 | $1,354.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,083.71 / $13,221.44 / $13,221.44
| Facility | | $5,083.71 | $13,221.44 | $13,221.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $959.97 / $1,313.64 / $2,399.92
| Professional | | $959.97 | $1,313.64 | $2,399.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,783.46 / $2,783.46 / $2,783.46
| Facility | | $2,783.46 | $2,783.46 | $2,783.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.48 / $1,313.64 / $2,087.60
| Professional | | $1,041.48 | $1,313.64 | $2,087.60 |