- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,359.88 / $2,359.88 / $2,359.88
| Facility | | $2,359.88 | $2,359.88 | $2,359.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,325.63 / $2,547.34 / $4,029.57
| Professional | | $2,325.63 | $2,547.34 | $4,029.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,535.22 / $34,613.83 / $66,228.75
| Facility | | $11,535.22 | $34,613.83 | $66,228.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,590.56 / $7,392.84 / $9,397.83
| Professional | | $4,590.56 | $7,392.84 | $9,397.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,813.68 / $8,248.77 / $19,843.53
| Facility | | $5,813.68 | $8,248.77 | $19,843.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,350.43 / $6,930.14 / $10,292.32
| Professional | | $4,350.43 | $6,930.14 | $10,292.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,285.16 / $7,541.35 / $15,624.83
| Facility | | $5,285.16 | $7,541.35 | $15,624.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,938.75 / $6,201.76 / $9,438.66
| Professional | | $3,938.75 | $6,201.76 | $9,438.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,433.10 / $3,824.01 / $6,523.32
| Facility | | $2,433.10 | $3,824.01 | $6,523.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,812.09 / $4,955.95 / $10,302.33
| Professional | | $2,812.09 | $4,955.95 | $10,302.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,720.00 / $3,500.00 / $8,152.00
| Facility | | $1,720.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,812.09 / $4,798.43 / $9,691.37
| Professional | | $2,812.09 | $4,798.43 | $9,691.37 |