- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,995.26 / $3,981.07
| Professional | | $1,513.56 | $1,995.26 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,677.35 / $20,892.96
| Facility | | $4,073.80 | $4,677.35 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,235.94 / $4,677.35
| Professional | | $1,778.28 | $3,235.94 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,888.44 / $7,762.47
| Facility | | $4,897.79 | $5,888.44 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,981.07 / $3,981.07
| Professional | | $3,235.94 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,630.27 / $3,162.28
| Facility | | $2,137.96 | $2,630.27 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,238.72
| Professional | | $1,548.82 | $1,548.82 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $4,897.79 / $9,772.37
| Facility | | $83.18 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $6,025.60
| Professional | | $3,981.07 | $3,981.07 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,630.27
| Professional | | $2,511.89 | $2,511.89 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,677.35 / $20,892.96
| Facility | | $4,073.80 | $4,677.35 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,235.94 / $5,128.61
| Professional | | $1,778.28 | $3,235.94 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.69 / $2,570.40 / $4,570.88
| Facility | | $2.69 | $2,570.40 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,570.40 / $3,981.07
| Professional | | $1,737.80 | $2,570.40 | $3,981.07 |