- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,355.07 / $1,355.07 / $1,355.07
| Facility | | $1,355.07 | $1,355.07 | $1,355.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,355.07 / $1,583.16 / $1,974.79
| Professional | | $1,355.07 | $1,583.16 | $1,974.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,589.41 / $5,567.22 / $10,996.30
| Facility | | $2,589.41 | $5,567.22 | $10,996.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,081.53 / $3,166.82 / $4,797.74
| Professional | | $2,081.53 | $3,166.82 | $4,797.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,014.46 / $4,274.88 / $10,283.81
| Facility | | $3,014.46 | $4,274.88 | $10,283.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,449.32 / $3,986.27 / $5,781.08
| Professional | | $2,449.32 | $3,986.27 | $5,781.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,450.54 / $3,908.27 / $8,097.49
| Facility | | $2,450.54 | $3,908.27 | $8,097.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,046.86 / $3,285.22 / $4,890.35
| Professional | | $2,046.86 | $3,285.22 | $4,890.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,766.43 / $2,505.37 / $3,728.93
| Facility | | $1,766.43 | $2,505.37 | $3,728.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.84 / $2,808.16 / $5,556.51
| Professional | | $1,645.84 | $2,808.16 | $5,556.51 |
- 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
- $1,770.57 / $3,321.98 / $5,339.58
| Professional | | $1,770.57 | $3,321.98 | $5,339.58 |