- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,670.36 / $1,670.36 / $1,670.36
| Facility | | $1,670.36 | $1,670.36 | $1,670.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,670.36 / $1,858.09 / $3,009.78
| Professional | | $1,670.36 | $1,858.09 | $3,009.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,420.45 / $10,347.54 / $24,212.22
| Facility | | $3,420.45 | $10,347.54 | $24,212.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.69 / $2,939.00 / $3,733.38
| Professional | | $1,866.69 | $2,939.00 | $3,733.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,174.27 / $4,936.66 / $6,357.49
| Facility | | $4,174.27 | $4,936.66 | $6,357.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,503.32 / $3,392.05 / $3,392.05
| Professional | | $2,503.32 | $3,392.05 | $3,392.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,297.39 / $3,297.39 / $3,297.39
| Facility | | $3,297.39 | $3,297.39 | $3,297.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.09 / $3,297.39 / $5,909.25
| Professional | | $2,407.09 | $3,297.39 | $5,909.25 |
- 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
- $3,095.30 / $3,095.30 / $3,250.06
| Professional | | $3,095.30 | $3,095.30 | $3,250.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,898.57 / $2,898.57 / $2,898.57
| Professional | | $2,898.57 | $2,898.57 | $2,898.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,347.54 / $24,212.22 / $24,212.22
| Facility | | $10,347.54 | $24,212.22 | $24,212.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,580.15 / $2,043.53 / $3,733.38
| Professional | | $1,580.15 | $2,043.53 | $3,733.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,097.31 / $5,097.31 / $5,097.31
| Facility | | $5,097.31 | $5,097.31 | $5,097.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.35 / $2,043.53 / $3,733.38
| Professional | | $1,493.35 | $2,043.53 | $3,733.38 |