- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Facility | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,412.54 / $2,238.72
| Professional | | $1,258.93 | $1,412.54 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $25,703.96 / $58,884.37
| Facility | | $8,317.64 | $25,703.96 | $58,884.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,311.31 / $5,011.87
| Professional | | $2,187.76 | $3,311.31 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,897.79 / $11,748.98
| Facility | | $3,467.37 | $4,897.79 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,981.07 / $6,025.60
| Professional | | $2,398.83 | $3,981.07 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,786.30 / $9,332.54
| Facility | | $3,801.89 | $4,786.30 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,388.44 / $5,370.32
| Professional | | $2,570.40 | $3,388.44 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,630.27 / $5,888.44
| Facility | | $1,412.54 | $2,630.27 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,570.40 / $7,585.78
| Professional | | $1,288.25 | $2,570.40 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $6,309.57 / $13,182.57
| Facility | | $1,584.89 | $6,309.57 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,454.71 / $4,897.79
| Professional | | $1,348.96 | $2,454.71 | $4,897.79 |