- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,137.96 / $5,248.07
| Professional | | $1,659.59 | $2,137.96 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,890.45 / $23,988.33
| Facility | | $3,388.44 | $3,890.45 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,951.21 / $3,890.45
| Professional | | $1,778.28 | $2,951.21 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,011.87 / $6,606.93
| Facility | | $4,073.80 | $5,011.87 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,388.44 / $3,388.44
| Professional | | $2,511.89 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,818.38 / $3,311.31
| Facility | | $2,187.76 | $2,818.38 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $3,311.31
| Professional | | $2,398.83 | $2,398.83 | $3,311.31 |
- 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
- $3,311.31 / $3,311.31 / $5,128.61
| Professional | | $3,311.31 | $3,311.31 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Professional | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,890.45 / $23,988.33
| Facility | | $3,388.44 | $3,890.45 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,951.21 / $4,365.16
| Professional | | $1,862.09 | $2,951.21 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.02 / $2,884.03 / $5,248.07
| Facility | | $3.02 | $2,884.03 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,754.23 / $3,311.31
| Professional | | $1,659.59 | $2,754.23 | $3,311.31 |