- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.47 / $1,216.47 / $1,216.47
| Facility | | $1,216.47 | $1,216.47 | $1,216.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,176.92 / $1,226.60 / $1,922.95
| Professional | | $1,176.92 | $1,226.60 | $1,922.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,390.89 / $13,126.55 / $25,424.06
| Facility | | $5,390.89 | $13,126.55 | $25,424.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,118.30 / $3,443.72 / $4,493.55
| Professional | | $2,118.30 | $3,443.72 | $4,493.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,944.72 / $4,178.13 / $10,051.07
| Facility | | $2,944.72 | $4,178.13 | $10,051.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,199.62 / $3,503.94 / $5,203.88
| Professional | | $2,199.62 | $3,503.94 | $5,203.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,677.02 / $3,819.82 / $7,914.23
| Facility | | $2,677.02 | $3,819.82 | $7,914.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.46 / $3,141.29 / $4,772.27
| Professional | | $1,991.46 | $3,141.29 | $4,772.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,235.00 / $2,055.83 / $5,694.70
| Facility | | $1,235.00 | $2,055.83 | $5,694.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.94 / $2,103.77 / $4,695.14
| Professional | | $1,189.94 | $2,103.77 | $4,695.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,457.00 / $9,370.00 / $12,774.00
| Facility | | $5,457.00 | $9,370.00 | $12,774.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.88 / $2,089.83 / $4,516.91
| Professional | | $1,150.88 | $2,089.83 | $4,516.91 |