- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,206.16 / $1,206.16 / $1,206.16
| Facility | | $1,206.16 | $1,206.16 | $1,206.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.91 / $1,275.61 / $2,171.77
| Professional | | $1,174.91 | $1,275.61 | $2,171.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,527.12 / $3,895.97 / $9,742.16
| Facility | | $1,527.12 | $3,895.97 | $9,742.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,226.41 / $3,738.31 / $4,534.03
| Professional | | $2,226.41 | $3,738.31 | $4,534.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,820.90 / $4,402.68 / $10,591.26
| Facility | | $2,820.90 | $4,402.68 | $10,591.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,218.04 / $4,001.57 / $5,501.68
| Professional | | $2,218.04 | $4,001.57 | $5,501.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,444.56 / $4,017.74 / $8,339.58
| Facility | | $2,444.56 | $4,017.74 | $8,339.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,218.04 / $3,650.78 / $5,030.14
| Professional | | $2,218.04 | $3,650.78 | $5,030.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.65 / $2,175.88 / $3,767.71
| Facility | | $1,230.65 | $2,175.88 | $3,767.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.33 / $3,013.20 / $11,470.21
| Professional | | $1,484.33 | $3,013.20 | $11,470.21 |
- 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
- $1,443.85 / $3,093.05 / $5,179.82
| Professional | | $1,443.85 | $3,093.05 | $5,179.82 |