- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,905.46 / $2,951.21
| Professional | | $1,548.82 | $1,905.46 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $6,606.93 / $22,908.68
| Facility | | $3,235.94 | $6,606.93 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,467.37 / $5,623.41
| Professional | | $2,398.83 | $3,467.37 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,370.32 / $12,882.50
| Facility | | $3,801.89 | $5,370.32 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,677.35 / $6,918.31
| Professional | | $3,019.95 | $4,677.35 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,248.07 / $10,232.93
| Facility | | $4,168.69 | $5,248.07 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,890.45 / $5,888.44
| Professional | | $2,884.03 | $3,890.45 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,019.95 / $4,466.84
| Facility | | $1,995.26 | $3,019.95 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,090.30 / $6,456.54
| Professional | | $1,862.09 | $3,090.30 | $6,456.54 |
- 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
- $1,995.26 / $3,235.94 / $6,309.57
| Professional | | $1,995.26 | $3,235.94 | $6,309.57 |