- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,905.46 / $3,467.37
| Professional | | $1,621.81 | $1,905.46 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $10,715.19 / $26,302.68
| Facility | | $5,754.40 | $10,715.19 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,365.16 / $6,606.93
| Professional | | $2,884.03 | $4,365.16 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,165.95 / $14,791.08
| Facility | | $3,890.45 | $6,165.95 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,677.35 / $7,413.10
| Professional | | $2,818.38 | $4,677.35 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,025.60 / $11,748.98
| Facility | | $4,786.30 | $6,025.60 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,168.69 / $6,760.83
| Professional | | $2,951.21 | $4,168.69 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,630.27 / $5,011.87
| Facility | | $1,621.81 | $2,630.27 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,311.31 / $13,182.57
| Professional | | $1,819.70 | $3,311.31 | $13,182.57 |
- 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
- $1,778.28 / $3,162.28 / $6,025.60
| Professional | | $1,778.28 | $3,162.28 | $6,025.60 |