- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Facility | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,584.89 / $2,398.83
| Professional | | $1,288.25 | $1,584.89 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,370.32 / $19,054.61
| Facility | | $2,691.53 | $5,370.32 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $4,677.35
| Professional | | $1,995.26 | $2,884.03 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,466.84 / $10,715.19
| Facility | | $3,162.28 | $4,466.84 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,801.89 / $5,754.40
| Professional | | $2,511.89 | $3,801.89 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,265.80 / $8,317.64
| Facility | | $3,467.37 | $4,265.80 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $4,786.30
| Professional | | $2,398.83 | $3,235.94 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,454.71 / $3,981.07
| Facility | | $1,698.24 | $2,454.71 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,570.40 / $5,248.07
| Professional | | $1,513.56 | $2,570.40 | $5,248.07 |
- 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
- $1,548.82 / $2,630.27 / $5,128.61
| Professional | | $1,548.82 | $2,630.27 | $5,128.61 |