- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,238.72 / $3,388.44
| Professional | | $1,819.70 | $2,238.72 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $7,585.78 / $26,915.35
| Facility | | $3,801.89 | $7,585.78 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,981.07 / $6,606.93
| Professional | | $2,818.38 | $3,981.07 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,309.57 / $14,791.08
| Facility | | $4,466.84 | $6,309.57 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,370.32 / $7,943.28
| Professional | | $3,467.37 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,025.60 / $11,748.98
| Facility | | $4,786.30 | $6,025.60 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,466.84 / $6,760.83
| Professional | | $3,311.31 | $4,466.84 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,235.94 / $5,128.61
| Facility | | $2,089.30 | $3,235.94 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,715.35 / $7,585.78
| Professional | | $2,187.76 | $3,715.35 | $7,585.78 |
- 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
- $2,187.76 / $3,801.89 / $7,413.10
| Professional | | $2,187.76 | $3,801.89 | $7,413.10 |