- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.69 / $1,042.69 / $1,042.69
| Facility | | $1,042.69 | $1,042.69 | $1,042.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.57 / $1,133.69 / $1,889.64
| Professional | | $1,022.57 | $1,133.69 | $1,889.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,358.83 / $10,066.44 / $21,331.89
| Facility | | $5,358.83 | $10,066.44 | $21,331.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.65 / $3,359.16 / $4,074.18
| Professional | | $1,980.65 | $3,359.16 | $4,074.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,428.30 / $3,789.94 / $9,117.21
| Facility | | $2,428.30 | $3,789.94 | $9,117.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,911.61 / $3,448.73 / $4,741.60
| Professional | | $1,911.61 | $3,448.73 | $4,741.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,104.33 / $3,458.57 / $7,178.91
| Facility | | $2,104.33 | $3,458.57 | $7,178.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,911.61 / $3,146.41 / $4,335.22
| Professional | | $1,911.61 | $3,146.41 | $4,335.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,099.52 / $1,859.40 / $3,305.60
| Facility | | $1,099.52 | $1,859.40 | $3,305.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.74 / $2,631.88 / $8,361.20
| Professional | | $1,301.74 | $2,631.88 | $8,361.20 |
- 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
- $1,204.64 / $2,381.94 / $4,492.70
| Professional | | $1,204.64 | $2,381.94 | $4,492.70 |