- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,137.96 / $3,548.13
| Professional | | $1,862.09 | $2,137.96 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $11,481.54 / $23,988.33
| Facility | | $5,011.87 | $11,481.54 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,786.30 / $7,762.47
| Professional | | $3,235.94 | $4,786.30 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $7,079.46 / $16,595.87
| Facility | | $5,011.87 | $7,079.46 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,025.60 / $9,120.11
| Professional | | $3,981.07 | $6,025.60 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $6,760.83 / $13,182.57
| Facility | | $5,370.32 | $6,760.83 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,128.61 / $7,585.78
| Professional | | $3,630.78 | $5,128.61 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,388.44 / $5,495.41
| Facility | | $2,089.30 | $3,388.44 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,265.80 / $11,220.18
| Professional | | $2,398.83 | $4,265.80 | $11,220.18 |
- 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
- $2,398.83 / $4,073.80 / $7,943.28
| Professional | | $2,398.83 | $4,073.80 | $7,943.28 |