- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.56 / $1,380.56 / $1,380.56
| Facility | | $1,380.56 | $1,380.56 | $1,380.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.56 / $1,615.34 / $2,016.86
| Professional | | $1,380.56 | $1,615.34 | $2,016.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,642.64 / $5,681.68 / $11,196.55
| Facility | | $2,642.64 | $5,681.68 | $11,196.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.80 / $3,231.92 / $4,896.37
| Professional | | $2,117.80 | $3,231.92 | $4,896.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,072.58 / $4,357.30 / $10,482.07
| Facility | | $3,072.58 | $4,357.30 | $10,482.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,488.75 / $4,050.44 / $5,874.14
| Professional | | $2,488.75 | $4,050.44 | $5,874.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,497.79 / $3,983.62 / $8,253.60
| Facility | | $2,497.79 | $3,983.62 | $8,253.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,079.81 / $3,338.10 / $4,969.08
| Professional | | $2,079.81 | $3,338.10 | $4,969.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,809.69 / $2,545.92 / $3,789.28
| Facility | | $1,809.69 | $2,545.92 | $3,789.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,683.53 / $2,861.96 / $5,655.08
| Professional | | $1,683.53 | $2,861.96 | $5,655.08 |
- 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
- $1,780.19 / $3,202.70 / $5,372.39
| Professional | | $1,780.19 | $3,202.70 | $5,372.39 |