- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,258.93 / $1,949.84
| Professional | | $1,023.29 | $1,258.93 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,365.16 / $15,135.61
| Facility | | $2,187.76 | $4,365.16 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $3,801.89
| Professional | | $1,778.28 | $2,398.83 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,630.78 / $8,511.38
| Facility | | $2,570.40 | $3,630.78 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,090.30 / $4,570.88
| Professional | | $2,041.74 | $3,090.30 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,467.37 / $6,760.83
| Facility | | $2,754.23 | $3,467.37 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,570.40 / $3,890.45
| Professional | | $1,949.84 | $2,570.40 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,995.26 / $3,981.07
| Facility | | $1,348.96 | $1,995.26 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,041.74 / $4,265.80
| Professional | | $1,202.26 | $2,041.74 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,467.37 / $8,511.38
| Facility | | $1,584.89 | $3,467.37 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,089.30 / $4,168.69
| Professional | | $1,258.93 | $2,089.30 | $4,168.69 |