- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,198.09 / $1,198.09 / $1,198.09
| Facility | | $1,198.09 | $1,198.09 | $1,198.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,198.09 / $1,198.09 / $1,732.35
| Professional | | $1,198.09 | $1,198.09 | $1,732.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.82 / $5,318.63 / $10,424.81
| Facility | | $2,398.82 | $5,318.63 | $10,424.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,051.33 / $3,167.65 / $4,445.56
| Professional | | $2,051.33 | $3,167.65 | $4,445.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,785.37 / $3,950.00 / $9,502.25
| Facility | | $2,785.37 | $3,950.00 | $9,502.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,261.01 / $3,808.29 / $5,424.49
| Professional | | $2,261.01 | $3,808.29 | $5,424.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,264.30 / $3,611.24 / $7,482.09
| Facility | | $2,264.30 | $3,611.24 | $7,482.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,990.61 / $3,406.53 / $4,514.38
| Professional | | $1,990.61 | $3,406.53 | $4,514.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,586.54 / $2,024.79 / $3,442.56
| Facility | | $1,586.54 | $2,024.79 | $3,442.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,595.17 / $3,067.25 / $6,595.64
| Professional | | $1,595.17 | $3,067.25 | $6,595.64 |
- 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
- $1,591.64 / $2,824.03 / $4,960.68
| Professional | | $1,591.64 | $2,824.03 | $4,960.68 |