- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,567.91 / $1,567.91 / $1,567.91
| Facility | | $1,567.91 | $1,567.91 | $1,567.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,567.91 / $1,835.62 / $2,294.50
| Professional | | $1,567.91 | $1,835.62 | $2,294.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,005.42 / $6,445.82 / $12,646.89
| Facility | | $3,005.42 | $6,445.82 | $12,646.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,413.21 / $3,675.59 / $5,568.54
| Professional | | $2,413.21 | $3,675.59 | $5,568.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,479.39 / $4,934.21 / $11,869.91
| Facility | | $3,479.39 | $4,934.21 | $11,869.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,823.21 / $4,594.78 / $6,663.56
| Professional | | $2,823.21 | $4,594.78 | $6,663.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,828.50 / $4,511.05 / $9,346.39
| Facility | | $2,828.50 | $4,511.05 | $9,346.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,359.32 / $3,786.71 / $5,636.87
| Professional | | $2,359.32 | $3,786.71 | $5,636.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,097.00 / $2,888.46 / $3,954.00
| Facility | | $2,097.00 | $2,888.46 | $3,954.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,911.83 / $3,270.92 / $6,461.96
| Professional | | $1,911.83 | $3,270.92 | $6,461.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.00 / $3,236.00 / $5,530.00
| Facility | | $1,445.00 | $3,236.00 | $5,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,923.82 / $3,236.18 / $6,138.93
| Professional | | $1,923.82 | $3,236.18 | $6,138.93 |