- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,646.16 / $1,646.16 / $1,646.16
| Facility | | $1,646.16 | $1,646.16 | $1,646.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,646.16 / $1,928.25 / $2,411.46
| Professional | | $1,646.16 | $1,928.25 | $2,411.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,159.21 / $6,792.29 / $13,424.98
| Facility | | $3,159.21 | $6,792.29 | $13,424.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,533.06 / $3,863.67 / $5,853.48
| Professional | | $2,533.06 | $3,863.67 | $5,853.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,652.06 / $5,179.07 / $12,458.95
| Facility | | $3,652.06 | $5,179.07 | $12,458.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,961.89 / $4,820.47 / $6,990.88
| Professional | | $2,961.89 | $4,820.47 | $6,990.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,968.86 / $4,734.91 / $9,810.20
| Facility | | $2,968.86 | $4,734.91 | $9,810.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,475.21 / $3,972.71 / $5,913.76
| Professional | | $2,475.21 | $3,972.71 | $5,913.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,077.94 / $3,029.41 / $4,093.76
| Facility | | $2,077.94 | $3,029.41 | $4,093.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.67 / $3,438.92 / $6,791.04
| Professional | | $1,997.67 | $3,438.92 | $6,791.04 |
- 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
- $2,128.17 / $3,721.97 / $6,527.87
| Professional | | $2,128.17 | $3,721.97 | $6,527.87 |