- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $5,011.87
| Facility | | $1,288.25 | $1,288.25 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,380.38 / $2,238.72
| Professional | | $1,202.26 | $1,380.38 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,128.31 / $20,417.38
| Facility | | $4,466.84 | $8,128.31 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,388.44 / $5,128.61
| Professional | | $2,290.87 | $3,388.44 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,011.87 / $12,022.64
| Facility | | $3,548.13 | $5,011.87 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,073.80 / $6,165.95
| Professional | | $2,454.71 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,897.79 / $9,549.93
| Facility | | $3,890.45 | $4,897.79 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,467.37 / $5,495.41
| Professional | | $2,630.27 | $3,467.37 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,398.83 / $4,677.35
| Facility | | $1,258.93 | $2,398.83 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,511.89 / $7,585.78
| Professional | | $1,258.93 | $2,511.89 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,715.35 / $7,079.46
| Facility | | $1,905.46 | $3,715.35 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,398.83 / $4,786.30
| Professional | | $1,258.93 | $2,398.83 | $4,786.30 |