- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,412.54 / $2,187.76
| Professional | | $1,148.15 | $1,412.54 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,897.79 / $16,982.44
| Facility | | $2,398.83 | $4,897.79 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,570.40 / $4,168.69
| Professional | | $1,819.70 | $2,570.40 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,981.07 / $9,549.93
| Facility | | $2,818.38 | $3,981.07 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,388.44 / $5,128.61
| Professional | | $2,238.72 | $3,388.44 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,801.89 / $7,585.78
| Facility | | $3,090.30 | $3,801.89 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,884.03 / $4,365.16
| Professional | | $2,137.96 | $2,884.03 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,818.38 / $13,182.57
| Facility | | $1,621.81 | $2,818.38 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,290.87 / $4,786.30
| Professional | | $1,348.96 | $2,290.87 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $11,220.18 / $26,915.35
| Facility | | $1,584.89 | $11,220.18 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,344.23 / $4,677.35
| Professional | | $1,445.44 | $2,344.23 | $4,677.35 |