- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.93 / $1,148.93 / $6,575.00
| Facility | | $1,148.93 | $1,148.93 | $6,575.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.40 / $1,170.16 / $1,827.89
| Professional | | $1,123.40 | $1,170.16 | $1,827.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,382.87 / $13,126.55 / $25,424.06
| Facility | | $5,382.87 | $13,126.55 | $25,424.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,060.79 / $3,284.27 / $4,285.47
| Professional | | $2,060.79 | $3,284.27 | $4,285.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,788.98 / $3,957.16 / $9,519.49
| Facility | | $2,788.98 | $3,957.16 | $9,519.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,090.76 / $3,330.53 / $4,946.35
| Professional | | $2,090.76 | $3,330.53 | $4,946.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,535.44 / $3,617.80 / $7,495.66
| Facility | | $2,535.44 | $3,617.80 | $7,495.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,892.91 / $2,977.72 / $4,536.10
| Professional | | $1,892.91 | $2,977.72 | $4,536.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,243.48 / $2,000.39 / $5,913.00
| Facility | | $1,243.48 | $2,000.39 | $5,913.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.08 / $2,288.28 / $4,603.54
| Professional | | $1,253.08 | $2,288.28 | $4,603.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,457.00 / $11,890.00 / $23,633.78
| Facility | | $5,457.00 | $11,890.00 | $23,633.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.08 / $2,151.48 / $4,440.52
| Professional | | $1,253.08 | $2,151.48 | $4,440.52 |