- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Facility | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,548.82 / $2,884.03
| Professional | | $1,318.26 | $1,548.82 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $21,877.62 / $47,863.01
| Facility | | $9,120.11 | $21,877.62 | $47,863.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,467.37 / $5,128.61
| Professional | | $2,238.72 | $3,467.37 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,897.79 / $11,481.54
| Facility | | $3,019.95 | $4,897.79 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,715.35 / $5,754.40
| Professional | | $2,238.72 | $3,715.35 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,677.35 / $9,120.11
| Facility | | $3,715.35 | $4,677.35 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,311.31 / $5,248.07
| Professional | | $2,344.23 | $3,311.31 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,137.96 / $3,981.07
| Facility | | $1,318.26 | $2,137.96 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,691.53 / $10,232.93
| Professional | | $1,479.11 | $2,691.53 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,311.31 / $8,511.38
| Facility | | $794.33 | $3,311.31 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,570.40 / $4,897.79
| Professional | | $1,479.11 | $2,570.40 | $4,897.79 |