- 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 / $2,570.40
| Professional | | $1,380.38 | $1,659.59 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,754.40 / $19,498.45
| Facility | | $2,884.03 | $5,754.40 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,090.30 / $5,011.87
| Professional | | $2,137.96 | $3,090.30 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,786.30 / $11,220.18
| Facility | | $3,388.44 | $4,786.30 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,073.80 / $6,025.60
| Professional | | $2,691.53 | $4,073.80 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,570.88 / $8,912.51
| Facility | | $3,630.78 | $4,570.88 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,388.44 / $5,128.61
| Professional | | $2,570.40 | $3,388.44 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,630.27 / $3,981.07
| Facility | | $1,778.28 | $2,630.27 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,691.53 / $5,623.41
| Professional | | $1,621.81 | $2,691.53 | $5,623.41 |
- 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 / $2,818.38 / $5,495.41
| Professional | | $1,737.80 | $2,818.38 | $5,495.41 |