- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,389.57 / $1,389.57 / $1,389.57
| Facility | | $1,389.57 | $1,389.57 | $1,389.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.99 / $1,389.57 / $2,030.54
| Professional | | $1,326.99 | $1,389.57 | $2,030.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,640.67 / $5,677.44 / $11,348.16
| Facility | | $2,640.67 | $5,677.44 | $11,348.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.59 / $3,229.50 / $4,892.72
| Professional | | $2,123.59 | $3,229.50 | $4,892.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,076.79 / $4,363.27 / $10,496.44
| Facility | | $3,076.79 | $4,363.27 | $10,496.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,501.66 / $4,071.46 / $5,904.63
| Professional | | $2,501.66 | $4,071.46 | $5,904.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,501.21 / $3,989.08 / $8,264.91
| Facility | | $2,501.21 | $3,989.08 | $8,264.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,090.61 / $3,355.42 / $4,994.85
| Professional | | $2,090.61 | $3,355.42 | $4,994.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,788.43 / $2,559.02 / $3,808.77
| Facility | | $1,788.43 | $2,559.02 | $3,808.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.58 / $2,893.19 / $5,714.77
| Professional | | $1,700.58 | $2,893.19 | $5,714.77 |
- 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
- $1,700.58 / $2,861.63 / $5,493.30
| Professional | | $1,700.58 | $2,861.63 | $5,493.30 |