- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,949.84 / $3,388.44
| Professional | | $1,737.80 | $1,949.84 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $10,964.78 / $23,988.33
| Facility | | $5,011.87 | $10,964.78 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,466.84 / $7,244.36
| Professional | | $3,019.95 | $4,466.84 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,606.93 / $15,488.17
| Facility | | $4,677.35 | $6,606.93 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,623.41 / $8,317.64
| Professional | | $3,630.78 | $5,623.41 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,309.57 / $12,302.69
| Facility | | $5,011.87 | $6,309.57 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,677.35 / $7,079.46
| Professional | | $3,388.44 | $4,677.35 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,162.28 / $5,128.61
| Facility | | $1,905.46 | $3,162.28 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,981.07 / $10,471.29
| Professional | | $2,344.23 | $3,981.07 | $10,471.29 |
- 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
- $2,344.23 / $3,801.89 / $7,413.10
| Professional | | $2,344.23 | $3,801.89 | $7,413.10 |