- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,127.26 / $1,127.26 / $1,127.26
| Facility | | $1,127.26 | $1,127.26 | $1,127.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.26 / $1,329.53 / $1,674.71
| Professional | | $1,127.26 | $1,329.53 | $1,674.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,234.55 / $9,855.66 / $20,316.56
| Facility | | $5,234.55 | $9,855.66 | $20,316.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,764.57 / $2,688.58 / $4,073.21
| Professional | | $1,764.57 | $2,688.58 | $4,073.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,495.63 / $3,539.11 / $8,513.81
| Facility | | $2,495.63 | $3,539.11 | $8,513.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,023.76 / $3,293.68 / $4,776.64
| Professional | | $2,023.76 | $3,293.68 | $4,776.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,028.77 / $3,235.60 / $6,703.79
| Facility | | $2,028.77 | $3,235.60 | $6,703.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,691.23 / $2,714.43 / $4,040.68
| Professional | | $1,691.23 | $2,714.43 | $4,040.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,671.93 / $2,070.75 / $3,500.00
| Facility | | $1,671.93 | $2,070.75 | $3,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.73 / $2,392.78 / $4,700.51
| Professional | | $1,429.73 | $2,392.78 | $4,700.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $3,500.00 / $8,152.00
| Facility | | $1,751.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.92 / $2,576.21 / $4,622.16
| Professional | | $1,480.92 | $2,576.21 | $4,622.16 |