- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,215.73 / $1,215.73 / $1,215.73
| Facility | | $1,215.73 | $1,215.73 | $1,215.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.75 / $1,327.83 / $2,214.06
| Professional | | $1,199.75 | $1,327.83 | $2,214.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,662.57 / $8,001.58 / $14,508.52
| Facility | | $4,662.57 | $8,001.58 | $14,508.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.83 / $3,942.40 / $4,781.56
| Professional | | $2,326.83 | $3,942.40 | $4,781.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,831.61 / $4,419.41 / $10,631.49
| Facility | | $2,831.61 | $4,419.41 | $10,631.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,253.46 / $4,027.48 / $5,537.30
| Professional | | $2,253.46 | $4,027.48 | $5,537.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,453.84 / $4,033.00 / $8,371.25
| Facility | | $2,453.84 | $4,033.00 | $8,371.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,232.41 / $3,674.42 / $5,062.72
| Professional | | $2,232.41 | $3,674.42 | $5,062.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,295.93 / $2,171.23 / $3,789.38
| Facility | | $1,295.93 | $2,171.23 | $3,789.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,529.96 / $3,078.41 / $9,845.53
| Professional | | $1,529.96 | $3,078.41 | $9,845.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $796.00 / $3,500.00 / $8,152.00
| Facility | | $796.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,467.53 / $2,803.98 / $5,359.65
| Professional | | $1,467.53 | $2,803.98 | $5,359.65 |