- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,513.56 / $2,290.87
| Professional | | $1,230.27 | $1,513.56 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,128.61 / $18,197.01
| Facility | | $2,570.40 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,691.53 / $4,466.84
| Professional | | $1,862.09 | $2,691.53 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,265.80 / $10,232.93
| Facility | | $3,019.95 | $4,265.80 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,630.78 / $5,495.41
| Professional | | $2,398.83 | $3,630.78 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,073.80 / $7,943.28
| Facility | | $3,235.94 | $4,073.80 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,019.95 / $4,570.88
| Professional | | $2,290.87 | $3,019.95 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,344.23 / $3,981.07
| Facility | | $1,698.24 | $2,344.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,511.89 / $5,128.61
| Professional | | $1,445.44 | $2,511.89 | $5,128.61 |
- 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
- $1,584.89 / $2,511.89 / $4,897.79
| Professional | | $1,584.89 | $2,511.89 | $4,897.79 |