- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,820.29 / $1,820.29 / $1,820.29
| Facility | | $1,820.29 | $1,820.29 | $1,820.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,820.29 / $1,827.60 / $3,152.61
| Professional | | $1,820.29 | $1,827.60 | $3,152.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,727.46 / $11,126.47 / $19,065.24
| Facility | | $3,727.46 | $11,126.47 | $19,065.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.54 / $3,004.04 / $4,068.48
| Professional | | $1,822.54 | $3,004.04 | $4,068.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,421.89 / $5,379.75 / $6,928.10
| Facility | | $4,421.89 | $5,379.75 | $6,928.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,000.82 / $3,501.96 / $3,501.96
| Professional | | $3,000.82 | $3,501.96 | $3,501.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.71 / $2,407.63 / $2,920.68
| Facility | | $2,282.71 | $2,407.63 | $2,920.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.39 / $1,666.39 / $4,710.75
| Professional | | $1,666.39 | $1,666.39 | $4,710.75 |
- 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
- $3,373.12 / $3,373.12 / $3,541.78
| Professional | | $3,373.12 | $3,373.12 | $3,541.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,895.32 / $2,895.32 / $2,895.32
| Professional | | $2,895.32 | $2,895.32 | $2,895.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,248.68 / $19,065.24 / $19,065.24
| Facility | | $8,248.68 | $19,065.24 | $19,065.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,627.39 / $2,226.94 / $4,068.48
| Professional | | $1,627.39 | $2,226.94 | $4,068.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,982.23 / $1,982.23 / $1,982.23
| Facility | | $1,982.23 | $1,982.23 | $1,982.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,721.98 / $2,226.94 / $4,045.58
| Professional | | $1,721.98 | $2,226.94 | $4,045.58 |