- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,290.87 / $3,890.45
| Professional | | $1,949.84 | $2,290.87 | $3,890.45 |
- 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
- $3,388.44 / $5,128.61 / $8,128.31
| Professional | | $3,388.44 | $5,128.61 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $7,413.10 / $17,782.79
| Facility | | $5,248.07 | $7,413.10 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $6,456.54 / $9,549.93
| Professional | | $4,168.69 | $6,456.54 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $7,244.36 / $14,125.38
| Facility | | $5,754.40 | $7,244.36 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,370.32 / $8,128.31
| Professional | | $3,890.45 | $5,370.32 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,388.44 / $5,754.40
| Facility | | $2,089.30 | $3,388.44 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,570.88 / $12,022.64
| Professional | | $2,691.53 | $4,570.88 | $12,022.64 |
- 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
- $2,630.27 / $4,365.16 / $8,511.38
| Professional | | $2,630.27 | $4,365.16 | $8,511.38 |