- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $5,011.87
| Facility | | $1,047.13 | $1,047.13 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,096.48 / $1,819.70
| Professional | | $912.01 | $1,096.48 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,888.44 / $16,595.87
| Facility | | $3,630.78 | $5,888.44 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,137.96 / $3,467.37
| Professional | | $1,445.44 | $2,137.96 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,630.78 / $8,709.64
| Facility | | $2,570.40 | $3,630.78 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,818.38 / $4,570.88
| Professional | | $1,659.59 | $2,818.38 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,467.37 / $6,918.31
| Facility | | $2,818.38 | $3,467.37 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,454.71 / $3,890.45
| Professional | | $1,862.09 | $2,454.71 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,778.28 / $5,623.41
| Facility | | $1,047.13 | $1,778.28 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,659.59 / $4,073.80
| Professional | | $933.25 | $1,659.59 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,248.07 / $8,912.51
| Facility | | $2,884.03 | $5,248.07 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,659.59 / $3,467.37
| Professional | | $1,000.00 | $1,659.59 | $3,467.37 |