- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,082.63 / $1,082.63 / $1,082.63
| Facility | | $1,082.63 | $1,082.63 | $1,082.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.63 / $1,082.63 / $1,826.13
| Professional | | $1,082.63 | $1,082.63 | $1,826.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,398.38 / $4,410.49 / $13,749.35
| Facility | | $1,398.38 | $4,410.49 | $13,749.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.78 / $1,718.87 / $2,419.75
| Professional | | $1,083.78 | $1,718.87 | $2,419.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,629.95 / $3,199.64 / $4,120.53
| Facility | | $2,629.95 | $3,199.64 | $4,120.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,784.75 / $2,198.52 / $2,198.52
| Professional | | $1,784.75 | $2,198.52 | $2,198.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,433.22 / $1,599.98 / $1,737.10
| Facility | | $1,433.22 | $1,599.98 | $1,737.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.99 / $1,599.98 / $2,867.25
| Professional | | $1,167.99 | $1,599.98 | $2,867.25 |
- 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
- $2,006.19 / $2,006.19 / $2,106.50
| Professional | | $2,006.19 | $2,006.19 | $2,106.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,679.58 / $1,679.58 / $1,679.58
| Facility | | $1,679.58 | $1,679.58 | $1,679.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,679.58 / $1,679.58 / $1,679.58
| Professional | | $1,679.58 | $1,679.58 | $1,679.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,020.89 / $13,749.35 / $13,749.35
| Facility | | $5,020.89 | $13,749.35 | $13,749.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.90 / $1,324.49 / $2,419.75
| Professional | | $967.90 | $1,324.49 | $2,419.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.15 / $1,324.49 / $2,172.39
| Professional | | $1,076.15 | $1,324.49 | $2,172.39 |