- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $2,511.89
| Professional | | $1,288.25 | $1,698.24 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Professional | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,165.95 / $7,585.78
| Professional | | $2,398.83 | $6,165.95 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,344.23 / $3,467.37
| Facility | | $1,905.46 | $2,344.23 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,511.89 / $3,388.44
| Professional | | $2,290.87 | $2,511.89 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,090.30 / $3,467.37
| Facility | | $3,019.95 | $3,090.30 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Professional | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,570.40 / $3,890.45
| Facility | | $1,584.89 | $2,570.40 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $2,691.53 / $3,235.94
| Professional | | $87.10 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,365.16 / $12,022.64
| Facility | | $2,570.40 | $4,365.16 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,467.37 / $3,467.37
| Professional | | $3,162.28 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,949.84 / $6,165.95
| Facility | | $1,862.09 | $1,949.84 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,412.54 / $2,691.53
| Professional | | $1,288.25 | $1,412.54 | $2,691.53 |