- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,061.33 / $1,061.33 / $1,061.33
| Facility | | $1,061.33 | $1,061.33 | $1,061.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.28 / $1,154.71 / $1,927.17
| Professional | | $1,050.28 | $1,154.71 | $1,927.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $934.71 / $2,401.69 / $8,837.48
| Facility | | $934.71 | $2,401.69 | $8,837.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,023.78 / $3,429.76 / $4,159.81
| Professional | | $2,023.78 | $3,429.76 | $4,159.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,472.67 / $3,859.22 / $9,283.87
| Facility | | $2,472.67 | $3,859.22 | $9,283.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.52 / $3,513.52 / $4,830.67
| Professional | | $1,947.52 | $3,513.52 | $4,830.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,142.80 / $3,521.79 / $7,310.14
| Facility | | $2,142.80 | $3,521.79 | $7,310.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.52 / $3,205.52 / $4,416.64
| Professional | | $1,947.52 | $3,205.52 | $4,416.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.26 / $1,894.81 / $3,368.54
| Facility | | $1,122.26 | $1,894.81 | $3,368.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,327.61 / $2,679.28 / $8,531.60
| Professional | | $1,327.61 | $2,679.28 | $8,531.60 |
- 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
- $1,275.70 / $2,433.13 / $4,650.80
| Professional | | $1,275.70 | $2,433.13 | $4,650.80 |