- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,778.28 / $2,754.23
| Professional | | $1,445.44 | $1,778.28 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,495.41 / $20,417.38
| Facility | | $2,818.38 | $5,495.41 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,951.21 / $4,677.35
| Professional | | $1,949.84 | $2,951.21 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,011.87 / $12,022.64
| Facility | | $3,548.13 | $5,011.87 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,715.35 / $5,623.41
| Professional | | $2,454.71 | $3,715.35 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,786.30 / $9,549.93
| Facility | | $3,890.45 | $4,786.30 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,162.28 / $4,786.30
| Professional | | $2,344.23 | $3,162.28 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,454.71 / $3,981.07
| Facility | | $1,737.80 | $2,454.71 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,818.38 / $5,888.44
| Professional | | $1,698.24 | $2,818.38 | $5,888.44 |
- 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
- $1,819.70 / $2,818.38 / $5,754.40
| Professional | | $1,819.70 | $2,818.38 | $5,754.40 |