- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,217.75 / $1,217.75 / $1,217.75
| Facility | | $1,217.75 | $1,217.75 | $1,217.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.51 / $1,328.09 / $2,211.96
| Professional | | $1,204.51 | $1,328.09 | $2,211.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,908.76 / $10,935.61 / $21,331.89
| Facility | | $5,908.76 | $10,935.61 | $21,331.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,319.46 / $3,934.65 / $4,772.17
| Professional | | $2,319.46 | $3,934.65 | $4,772.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,834.67 / $4,424.18 / $10,642.98
| Facility | | $2,834.67 | $4,424.18 | $10,642.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,248.07 / $4,024.24 / $5,532.85
| Professional | | $2,248.07 | $4,024.24 | $5,532.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,456.48 / $4,037.36 / $8,380.29
| Facility | | $2,456.48 | $4,037.36 | $8,380.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,230.61 / $3,671.47 / $5,058.66
| Professional | | $2,230.61 | $3,671.47 | $5,058.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,289.83 / $2,101.96 / $3,797.64
| Facility | | $1,289.83 | $2,101.96 | $3,797.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.25 / $3,081.38 / $9,785.04
| Professional | | $1,527.25 | $3,081.38 | $9,785.04 |
- 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
- $1,477.67 / $2,866.42 / $5,260.01
| Professional | | $1,477.67 | $2,866.42 | $5,260.01 |