- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,547.85 / $1,547.85 / $1,547.85
| Facility | | $1,547.85 | $1,547.85 | $1,547.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.85 / $1,811.11 / $2,262.56
| Professional | | $1,547.85 | $1,811.11 | $2,262.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,965.33 / $6,375.46 / $12,641.17
| Facility | | $2,965.33 | $6,375.46 | $12,641.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,380.62 / $3,626.57 / $5,494.26
| Professional | | $2,380.62 | $3,626.57 | $5,494.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.12 / $4,875.68 / $11,729.12
| Facility | | $3,438.12 | $4,875.68 | $11,729.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,790.58 / $4,541.67 / $6,586.55
| Professional | | $2,790.58 | $4,541.67 | $6,586.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,794.95 / $4,457.54 / $9,235.53
| Facility | | $2,794.95 | $4,457.54 | $9,235.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,332.05 / $3,742.94 / $5,571.72
| Professional | | $2,332.05 | $3,742.94 | $5,571.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,097.00 / $2,854.51 / $3,954.00
| Facility | | $2,097.00 | $2,854.51 | $3,954.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.61 / $3,223.02 / $6,370.00
| Professional | | $1,885.61 | $3,223.02 | $6,370.00 |
- 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
- $1,967.53 / $3,491.21 / $6,051.57
| Professional | | $1,967.53 | $3,491.21 | $6,051.57 |