- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $1,584.89
| Facility | | $1,584.89 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,819.70 / $2,691.53
| Professional | | $1,412.54 | $1,819.70 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,456.54 / $22,908.68
| Facility | | $3,162.28 | $6,456.54 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,311.31 / $5,495.41
| Professional | | $2,344.23 | $3,311.31 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,248.07 / $12,302.69
| Facility | | $3,715.35 | $5,248.07 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,466.84 / $6,606.93
| Professional | | $2,951.21 | $4,466.84 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,011.87 / $9,772.37
| Facility | | $3,981.07 | $5,011.87 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,715.35 / $5,623.41
| Professional | | $2,754.23 | $3,715.35 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,884.03 / $4,265.80
| Facility | | $1,737.80 | $2,884.03 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,090.30 / $6,456.54
| Professional | | $1,698.24 | $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
- $1,698.24 / $3,090.30 / $6,165.95
| Professional | | $1,698.24 | $3,090.30 | $6,165.95 |