- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,698.24
| Facility | | $1,202.26 | $1,202.26 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,230.27 / $2,290.87
| Professional | | $1,096.48 | $1,230.27 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,584.89
| Facility | | $1,288.25 | $1,288.25 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Professional | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,089.30 / $2,089.30
| Facility | | $1,862.09 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,819.70 / $7,244.36
| Professional | | $1,148.15 | $1,819.70 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $28,183.83
| Facility | | $28,183.83 | $28,183.83 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $35,481.34
| Facility | | $4,466.84 | $4,466.84 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,380.38 / $1,949.84
| Professional | | $933.25 | $1,380.38 | $1,949.84 |