- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,454.71
| Facility | | $2,290.87 | $2,290.87 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,818.38 / $4,570.88
| Professional | | $2,238.72 | $2,818.38 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.43 / $5,370.32 / $5,370.32
| Facility | | $79.43 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Facility | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,981.07
| Professional | | $2,884.03 | $2,884.03 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33,113.11 / $33,113.11 / $33,113.11
| Facility | | $33,113.11 | $33,113.11 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35,481.34 / $41,686.94 / $41,686.94
| Professional | | $35,481.34 | $41,686.94 | $41,686.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,570.88 / $7,244.36
| Facility | | $2,290.87 | $4,570.88 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,019.95 / $6,165.95
| Professional | | $2,290.87 | $3,019.95 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,884.03
| Professional | | $2,818.38 | $2,818.38 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,168.69 / $7,413.10
| Facility | | $2,290.87 | $4,168.69 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,981.07
| Professional | | $2,884.03 | $2,884.03 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,890.45 / $6,025.60
| Facility | | $1,995.26 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,235.94 / $3,981.07
| Professional | | $2,187.76 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Professional | | $5,370.32 | $5,370.32 | $5,370.32 |