- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,133.41 / $1,133.41 / $1,133.41
| Facility | | $1,133.41 | $1,133.41 | $1,133.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.41 / $1,184.60 / $1,800.09
| Professional | | $1,133.41 | $1,184.60 | $1,800.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,559.20 / $11,345.35 / $24,108.80
| Facility | | $5,559.20 | $11,345.35 | $24,108.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,070.35 / $3,193.69 / $4,487.27
| Professional | | $2,070.35 | $3,193.69 | $4,487.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,854.43 / $4,047.94 / $9,737.87
| Facility | | $2,854.43 | $4,047.94 | $9,737.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,320.16 / $3,902.72 / $5,566.38
| Professional | | $2,320.16 | $3,902.72 | $5,566.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,320.44 / $3,700.79 / $7,667.61
| Facility | | $2,320.44 | $3,700.79 | $7,667.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,042.68 / $3,495.64 / $4,632.46
| Professional | | $2,042.68 | $3,495.64 | $4,632.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,600.76 / $2,207.94 / $3,500.00
| Facility | | $1,600.76 | $2,207.94 | $3,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,582.03 / $3,049.11 / $4,888.22
| Professional | | $1,582.03 | $3,049.11 | $4,888.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $3,500.00 / $8,152.00
| Facility | | $1,751.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,508.87 / $2,807.33 / $4,746.84
| Professional | | $1,508.87 | $2,807.33 | $4,746.84 |