- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,370.32 / $7,943.28
| Facility | | $1,949.84 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,047.13 / $1,949.84
| Professional | | $851.14 | $1,047.13 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,090.30 / $6,025.60
| Facility | | $1,318.26 | $3,090.30 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,584.89 / $2,238.72
| Professional | | $954.99 | $1,584.89 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,621.81 / $2,187.76
| Facility | | $1,202.26 | $1,621.81 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,513.56 / $2,454.71
| Professional | | $977.24 | $1,513.56 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,445.44 / $5,248.07
| Professional | | $1,000.00 | $1,445.44 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $6,456.54 / $12,022.64
| Facility | | $1,737.80 | $6,456.54 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,348.96 / $2,187.76
| Professional | | $831.76 | $1,348.96 | $2,187.76 |