- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.26 / $1,052.26 / $3,511.00
| Facility | | $1,052.26 | $1,052.26 | $3,511.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.09 / $1,052.26 / $2,548.48
| Professional | | $887.09 | $1,052.26 | $2,548.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.60 / $2,389.50 / $2,986.87
| Professional | | $1,835.60 | $2,389.50 | $2,986.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,029.34 / $1,509.74 / $2,773.87
| Facility | | $1,029.34 | $1,509.74 | $2,773.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.83 / $2,217.64 / $7,862.72
| Professional | | $944.83 | $2,217.64 | $7,862.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,632.65 / $2,607.14 / $3,711.03
| Facility | | $1,632.65 | $2,607.14 | $3,711.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,259.76 / $2,176.08 / $2,862.36
| Professional | | $1,259.76 | $2,176.08 | $2,862.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.70 / $1,792.24 / $2,102.42
| Professional | | $1,082.70 | $1,792.24 | $2,102.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.83 / $1,876.82 / $2,919.50
| Professional | | $944.83 | $1,876.82 | $2,919.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,085.69 / $2,551.90 / $2,551.90
| Professional | | $2,085.69 | $2,551.90 | $2,551.90 |