- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,548.82 / $3,388.44
| Professional | | $1,202.26 | $1,548.82 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,884.03 / $17,782.79
| Facility | | $2,511.89 | $2,884.03 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,137.96 / $2,884.03
| Professional | | $1,258.93 | $2,137.96 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,630.78 / $4,786.30
| Facility | | $3,019.95 | $3,630.78 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,454.71 / $2,454.71
| Professional | | $1,995.26 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,041.74 / $2,137.96
| Facility | | $1,621.81 | $2,041.74 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,137.96
| Professional | | $1,548.82 | $1,548.82 | $2,137.96 |
- 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
- $2,454.71 / $2,454.71 / $3,715.35
| Professional | | $2,454.71 | $2,454.71 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Professional | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,884.03 / $17,782.79
| Facility | | $2,511.89 | $2,884.03 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,137.96 / $3,311.31
| Professional | | $1,318.26 | $2,137.96 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.24 / $2,089.30 / $3,801.89
| Facility | | $2.24 | $2,089.30 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,995.26 / $2,454.71
| Professional | | $1,202.26 | $1,995.26 | $2,454.71 |