- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,196.28 / $1,196.28 / $1,196.28
| Facility | | $1,196.28 | $1,196.28 | $1,196.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.97 / $1,305.86 / $2,178.05
| Professional | | $1,181.97 | $1,305.86 | $2,178.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,662.57 / $7,992.71 / $14,508.52
| Facility | | $4,662.57 | $7,992.71 | $14,508.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,288.81 / $3,879.52 / $4,705.30
| Professional | | $2,288.81 | $3,879.52 | $4,705.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,787.22 / $4,350.13 / $10,464.83
| Facility | | $2,787.22 | $4,350.13 | $10,464.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,216.61 / $3,961.62 / $5,446.75
| Professional | | $2,216.61 | $3,961.62 | $5,446.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,415.37 / $3,969.78 / $8,240.03
| Facility | | $2,415.37 | $3,969.78 | $8,240.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,195.90 / $3,614.33 / $4,979.93
| Professional | | $2,195.90 | $3,614.33 | $4,979.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,274.60 / $2,097.00 / $3,736.84
| Facility | | $1,274.60 | $2,097.00 | $3,736.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.67 / $3,027.65 / $9,644.56
| Professional | | $1,522.67 | $3,027.65 | $9,644.56 |
- 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
- $1,459.22 / $2,775.21 / $5,270.37
| Professional | | $1,459.22 | $2,775.21 | $5,270.37 |