- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,461.58 / $1,461.58 / $1,461.58
| Facility | | $1,461.58 | $1,461.58 | $1,461.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.58 / $1,541.50 / $2,661.82
| Professional | | $1,461.58 | $1,541.50 | $2,661.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,992.91 / $8,933.84 / $16,018.84
| Facility | | $2,992.91 | $8,933.84 | $16,018.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.44 / $2,484.94 / $3,266.73
| Professional | | $1,527.44 | $2,484.94 | $3,266.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,652.51 / $4,319.60 / $5,562.84
| Facility | | $3,652.51 | $4,319.60 | $5,562.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,190.42 / $2,968.07 / $2,968.07
| Professional | | $2,190.42 | $2,968.07 | $2,968.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.07 / $2,217.07 / $2,458.64
| Facility | | $2,217.07 | $2,217.07 | $2,458.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.46 / $2,217.07 / $3,973.13
| Professional | | $1,618.46 | $2,217.07 | $3,973.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $4,618.00 / $9,239.00
| Facility | | $83.43 | $4,618.00 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,708.41 / $2,708.41 / $2,843.83
| Professional | | $2,708.41 | $2,708.41 | $2,843.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.99 / $1,997.99 / $1,997.99
| Professional | | $1,997.99 | $1,997.99 | $1,997.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,957.42 / $16,018.84 / $16,018.84
| Facility | | $6,957.42 | $16,018.84 | $16,018.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.69 / $1,788.10 / $3,266.73
| Professional | | $1,306.69 | $1,788.10 | $3,266.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.44 / $2,018.42 / $2,301.38
| Facility | | $2.44 | $2,018.42 | $2,301.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.77 / $1,788.10 / $3,266.73
| Professional | | $1,437.77 | $1,788.10 | $3,266.73 |