- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,760.87 / $2,760.87 / $2,957.44
| Facility | | $2,760.87 | $2,760.87 | $2,957.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,760.87 / $2,760.87 / $2,760.87
| Professional | | $2,760.87 | $2,760.87 | $2,760.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.43 / $296.51 / $573.54
| Facility | | $225.43 | $296.51 | $573.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,040.43 / $6,613.93 / $6,860.32
| Professional | | $6,040.43 | $6,613.93 | $6,860.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,597.94 / $9,497.42 / $10,708.81
| Professional | | $7,597.94 | $9,497.42 | $10,708.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,505.93 / $2,760.87 / $19,869.87
| Facility | | $1,505.93 | $2,760.87 | $19,869.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,509.88 / $2,509.88 / $12,089.25
| Professional | | $2,509.88 | $2,509.88 | $12,089.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,019.76 / $8,617.25 / $10,708.81
| Facility | | $5,019.76 | $8,617.25 | $10,708.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,019.76 / $8,617.25 / $11,505.45
| Professional | | $5,019.76 | $8,617.25 | $11,505.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,894.26 / $4,894.26 / $8,533.59
| Professional | | $4,894.26 | $4,894.26 | $8,533.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,384.38 / $2,509.88 / $3,764.82
| Professional | | $2,384.38 | $2,509.88 | $3,764.82 |