- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,523.68 / $1,523.68 / $1,523.68
| Facility | | $1,523.68 | $1,523.68 | $1,523.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.68 / $1,523.68 / $2,710.35
| Professional | | $1,523.68 | $1,523.68 | $2,710.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,881.45 / $5,934.09 / $16,837.56
| Facility | | $1,881.45 | $5,934.09 | $16,837.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,688.09 / $2,601.29 / $3,405.52
| Professional | | $1,688.09 | $2,601.29 | $3,405.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,701.36 / $4,503.13 / $5,799.19
| Facility | | $3,701.36 | $4,503.13 | $5,799.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,283.50 / $3,094.17 / $3,094.17
| Professional | | $2,283.50 | $3,094.17 | $3,094.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,017.11 / $2,375.33 / $2,444.77
| Facility | | $2,017.11 | $2,375.33 | $2,444.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.99 / $2,375.32 / $4,257.00
| Professional | | $1,733.99 | $2,375.32 | $4,257.00 |
- 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
- $2,823.48 / $2,823.48 / $2,964.65
| Professional | | $2,823.48 | $2,823.48 | $2,964.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,149.78 / $2,149.78 / $2,149.78
| Professional | | $2,149.78 | $2,149.78 | $2,149.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,453.98 / $16,837.56 / $16,837.56
| Facility | | $7,453.98 | $16,837.56 | $16,837.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.74 / $1,864.08 / $3,405.52
| Professional | | $1,406.74 | $1,864.08 | $3,405.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,511.59 / $4,511.59 / $4,511.59
| Facility | | $4,511.59 | $4,511.59 | $4,511.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,514.57 / $1,977.04 / $3,405.52
| Professional | | $1,514.57 | $1,977.04 | $3,405.52 |