- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $10,964.78 / $11,748.98
| Facility | | $2,818.38 | $10,964.78 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,818.38 / $3,019.95
| Professional | | $2,344.23 | $2,818.38 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $10,715.19 / $10,964.78
| Facility | | $6,918.31 | $10,715.19 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,162.28 / $3,162.28
| Professional | | $2,290.87 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,623.41 / $9,332.54
| Facility | | $2,398.83 | $5,623.41 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,073.80 / $5,370.32
| Professional | | $2,818.38 | $4,073.80 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,818.38 / $3,548.13
| Facility | | $1,862.09 | $2,818.38 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,630.27
| Professional | | $2,290.87 | $2,290.87 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,548.13 / $4,265.80
| Facility | | $1,778.28 | $3,548.13 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,778.28 / $3,548.13
| Professional | | $1,584.89 | $1,778.28 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $16,595.87
| Facility | | $16,595.87 | $16,595.87 | $16,595.87 |