- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,187.76 / $3,715.35
| Professional | | $1,905.46 | $2,187.76 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $11,481.54 / $24,547.09
| Facility | | $5,011.87 | $11,481.54 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,897.79 / $7,943.28
| Professional | | $3,311.31 | $4,897.79 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $7,244.36 / $16,982.44
| Facility | | $5,128.61 | $7,244.36 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,165.95 / $9,120.11
| Professional | | $3,981.07 | $6,165.95 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,918.31 / $13,489.63
| Facility | | $5,495.41 | $6,918.31 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,128.61 / $7,762.47
| Professional | | $3,715.35 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,388.44 / $5,623.41
| Facility | | $2,089.30 | $3,388.44 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,365.16 / $11,481.54
| Professional | | $2,570.40 | $4,365.16 | $11,481.54 |
- 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
- $2,570.40 / $4,168.69 / $8,128.31
| Professional | | $2,570.40 | $4,168.69 | $8,128.31 |