- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,479.11 / $2,511.89
| Professional | | $1,288.25 | $1,479.11 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $8,709.64 / $22,908.68
| Facility | | $5,011.87 | $8,709.64 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,311.31 / $5,370.32
| Professional | | $2,187.76 | $3,311.31 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,897.79 / $11,481.54
| Facility | | $3,467.37 | $4,897.79 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,168.69 / $6,165.95
| Professional | | $2,691.53 | $4,168.69 | $6,165.95 |
- 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
- $2,511.89 / $3,467.37 / $5,248.07
| Professional | | $2,511.89 | $3,467.37 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,344.23 / $3,981.07
| Facility | | $1,698.24 | $2,344.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,951.21 / $7,762.47
| Professional | | $1,698.24 | $2,951.21 | $7,762.47 |
- 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
- $1,659.59 / $2,754.23 / $5,495.41
| Professional | | $1,659.59 | $2,754.23 | $5,495.41 |