- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,108.67 / $1,108.67 / $1,108.67
| Facility | | $1,108.67 | $1,108.67 | $1,108.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.67 / $1,200.52 / $2,059.60
| Professional | | $1,108.67 | $1,200.52 | $2,059.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,317.02 / $4,153.88 / $15,512.98
| Facility | | $1,317.02 | $4,153.88 | $15,512.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.33 / $1,883.60 / $2,477.94
| Professional | | $1,222.33 | $1,883.60 | $2,477.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,693.21 / $3,276.60 / $4,219.64
| Facility | | $2,693.21 | $3,276.60 | $4,219.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,827.68 / $2,251.39 / $2,251.39
| Professional | | $1,827.68 | $2,251.39 | $2,251.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,467.70 / $1,787.17 / $1,787.17
| Facility | | $1,467.70 | $1,787.17 | $1,787.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.63 / $1,304.63 / $3,724.50
| Professional | | $1,304.63 | $1,304.63 | $3,724.50 |
- 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
- $2,054.44 / $2,054.44 / $2,157.16
| Professional | | $2,054.44 | $2,054.44 | $2,157.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.65 / $1,556.65 / $1,556.65
| Professional | | $1,556.65 | $1,556.65 | $1,556.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,521.70 / $15,512.98 / $15,512.98
| Facility | | $6,521.70 | $15,512.98 | $15,512.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.62 / $1,414.67 / $2,477.94
| Professional | | $1,018.62 | $1,414.67 | $2,477.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.21 / $1,448.21 / $1,448.21
| Facility | | $1,448.21 | $1,448.21 | $1,448.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.04 / $1,435.63 / $2,477.94
| Professional | | $1,102.04 | $1,435.63 | $2,477.94 |