- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,895.75 / $1,895.75 / $1,895.75
| Facility | | $1,895.75 | $1,895.75 | $1,895.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.75 / $1,895.75 / $3,433.62
| Professional | | $1,895.75 | $1,895.75 | $3,433.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,584.94 / $8,152.93 / $25,846.18
| Facility | | $2,584.94 | $8,152.93 | $25,846.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,035.96 / $3,137.34 / $4,237.13
| Professional | | $2,035.96 | $3,137.34 | $4,237.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,605.21 / $5,602.76 / $7,215.30
| Facility | | $4,605.21 | $5,602.76 | $7,215.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,125.21 / $3,647.12 / $3,647.12
| Professional | | $3,125.21 | $3,647.12 | $3,647.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,509.66 / $2,550.04 / $3,041.75
| Facility | | $2,509.66 | $2,550.04 | $3,041.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,861.53 / $2,550.04 / $5,325.75
| Professional | | $1,861.53 | $2,550.04 | $5,325.75 |
- 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
- $3,512.95 / $3,512.95 / $3,688.60
| Professional | | $3,512.95 | $3,512.95 | $3,688.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,122.42 / $3,122.42 / $3,122.42
| Professional | | $3,122.42 | $3,122.42 | $3,122.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,325.45 / $25,846.18 / $25,846.18
| Facility | | $9,325.45 | $25,846.18 | $25,846.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,696.63 / $2,319.26 / $4,237.13
| Professional | | $1,696.63 | $2,319.26 | $4,237.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,441.30 / $5,441.30 / $5,441.30
| Facility | | $5,441.30 | $5,441.30 | $5,441.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,694.85 / $2,319.26 / $4,153.68
| Professional | | $1,694.85 | $2,319.26 | $4,153.68 |