- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,276.10 / $1,276.10 / $6,781.00
| Facility | | $1,276.10 | $1,276.10 | $6,781.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.57 / $1,298.85 / $2,032.95
| Professional | | $1,248.57 | $1,298.85 | $2,032.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,088.76 / $5,302.71 / $10,678.77
| Facility | | $2,088.76 | $5,302.71 | $10,678.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,266.23 / $3,648.87 / $4,761.24
| Professional | | $2,266.23 | $3,648.87 | $4,761.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,093.73 / $4,389.55 / $10,559.65
| Facility | | $3,093.73 | $4,389.55 | $10,559.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,320.36 / $3,696.27 / $5,489.54
| Professional | | $2,320.36 | $3,696.27 | $5,489.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,812.48 / $4,013.10 / $8,314.69
| Facility | | $2,812.48 | $4,013.10 | $8,314.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.78 / $3,304.72 / $5,034.22
| Professional | | $2,100.78 | $3,304.72 | $5,034.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,319.43 / $2,184.94 / $3,754.02
| Facility | | $1,319.43 | $2,184.94 | $3,754.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.20 / $2,515.62 / $5,129.33
| Professional | | $1,396.20 | $2,515.62 | $5,129.33 |
- 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
- $1,450.42 / $2,507.73 / $4,947.68
| Professional | | $1,450.42 | $2,507.73 | $4,947.68 |