- 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 / $1,949.84 / $3,467.37
| Professional | | $1,659.59 | $1,949.84 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,715.35 / $18,197.01
| Facility | | $3,630.78 | $3,715.35 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,884.03 / $3,890.45
| Professional | | $1,737.80 | $2,884.03 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,011.87 / $6,606.93
| Facility | | $4,265.80 | $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
- $2,511.89 / $2,511.89 / $2,818.38
| Facility | | $2,511.89 | $2,511.89 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $2,511.89
| Professional | | $1,862.09 | $1,862.09 | $2,511.89 |
- 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
- $3,388.44 / $3,388.44 / $5,128.61
| Professional | | $3,388.44 | $3,388.44 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Professional | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,715.35 / $18,197.01
| Facility | | $3,630.78 | $3,715.35 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,951.21 / $4,365.16
| Professional | | $1,737.80 | $2,951.21 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.82 / $2,630.27 / $4,786.30
| Facility | | $2.82 | $2,630.27 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,630.27 / $3,388.44
| Professional | | $1,659.59 | $2,630.27 | $3,388.44 |