- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,659.59 / $2,691.53
| Professional | | $1,380.38 | $1,659.59 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $8,709.64 / $20,892.96
| Facility | | $3,548.13 | $8,709.64 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,235.94 / $5,248.07
| Professional | | $2,290.87 | $3,235.94 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,011.87 / $11,748.98
| Facility | | $3,548.13 | $5,011.87 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,265.80 / $6,456.54
| Professional | | $2,754.23 | $4,265.80 | $6,456.54 |
- 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 / $3,548.13 / $5,370.32
| Professional | | $2,570.40 | $3,548.13 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,398.83 / $3,981.07
| Facility | | $1,659.59 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,019.95 / $7,943.28
| Professional | | $1,737.80 | $3,019.95 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,467.37 / $8,511.38
| Facility | | $1,584.89 | $3,467.37 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,884.03 / $5,754.40
| Professional | | $1,737.80 | $2,884.03 | $5,754.40 |