- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $1,584.89
| Facility | | $1,584.89 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,041.74 / $4,466.84
| Professional | | $1,584.89 | $2,041.74 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,715.35 / $22,908.68
| Facility | | $3,235.94 | $3,715.35 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,818.38 / $3,715.35
| Professional | | $1,698.24 | $2,818.38 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,786.30 / $6,309.57
| Facility | | $3,890.45 | $4,786.30 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,235.94
| Professional | | $2,398.83 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,691.53 / $3,162.28
| Facility | | $2,089.30 | $2,691.53 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $3,162.28
| Professional | | $2,290.87 | $2,290.87 | $3,162.28 |
- 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
- $3,162.28 / $3,162.28 / $4,897.79
| Professional | | $3,162.28 | $3,162.28 | $4,897.79 |
- 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
- $3,235.94 / $3,715.35 / $22,908.68
| Facility | | $3,235.94 | $3,715.35 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,818.38 / $4,168.69
| Professional | | $1,778.28 | $2,818.38 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.88 / $2,754.23 / $4,897.79
| Facility | | $2.88 | $2,754.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,630.27 / $3,162.28
| Professional | | $1,584.89 | $2,630.27 | $3,162.28 |