- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,059.88 / $2,059.88 / $2,059.88
| Facility | | $2,059.88 | $2,059.88 | $2,059.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.88 / $2,172.55 / $3,751.45
| Professional | | $2,059.88 | $2,172.55 | $3,751.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,218.07 / $12,590.94 / $22,493.11
| Facility | | $4,218.07 | $12,590.94 | $22,493.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,152.71 / $3,502.18 / $4,603.97
| Professional | | $2,152.71 | $3,502.18 | $4,603.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,147.66 / $6,087.84 / $7,839.99
| Facility | | $5,147.66 | $6,087.84 | $7,839.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,395.79 / $4,183.05 / $4,183.05
| Professional | | $3,395.79 | $4,183.05 | $4,183.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,886.72 / $2,886.72 / $3,465.09
| Facility | | $2,886.72 | $2,886.72 | $3,465.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,107.31 / $2,886.72 / $5,599.88
| Professional | | $2,107.31 | $2,886.72 | $5,599.88 |
- 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
- $3,817.10 / $3,817.10 / $4,007.96
| Professional | | $3,817.10 | $3,817.10 | $4,007.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,441.78 / $3,441.78 / $3,441.78
| Professional | | $3,441.78 | $3,441.78 | $3,441.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,805.49 / $22,493.11 / $22,493.11
| Facility | | $9,805.49 | $22,493.11 | $22,493.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,841.59 / $2,520.06 / $4,603.97
| Professional | | $1,841.59 | $2,520.06 | $4,603.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,753.36 / $5,753.36 / $5,753.36
| Facility | | $5,753.36 | $5,753.36 | $5,753.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,047.55 / $2,520.06 / $4,603.97
| Professional | | $2,047.55 | $2,520.06 | $4,603.97 |