- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,597.17 / $1,597.17 / $1,597.17
| Facility | | $1,597.17 | $1,597.17 | $1,597.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,597.17 / $1,597.17 / $2,335.63
| Professional | | $1,597.17 | $1,597.17 | $2,335.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,059.31 / $6,577.52 / $12,975.86
| Facility | | $3,059.31 | $6,577.52 | $12,975.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,456.84 / $3,725.40 / $5,668.39
| Professional | | $2,456.84 | $3,725.40 | $5,668.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,546.77 / $5,029.77 / $12,099.78
| Facility | | $3,546.77 | $5,029.77 | $12,099.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,877.59 / $4,683.29 / $6,791.92
| Professional | | $2,877.59 | $4,683.29 | $6,791.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,883.27 / $4,598.41 / $9,527.39
| Facility | | $2,883.27 | $4,598.41 | $9,527.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.77 / $3,859.65 / $5,745.45
| Professional | | $2,404.77 | $3,859.65 | $5,745.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,097.00 / $2,944.08 / $4,001.12
| Facility | | $2,097.00 | $2,944.08 | $4,001.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,945.42 / $3,326.85 / $6,574.11
| Professional | | $1,945.42 | $3,326.85 | $6,574.11 |
- 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
- $1,945.42 / $3,414.78 / $6,574.11
| Professional | | $1,945.42 | $3,414.78 | $6,574.11 |