- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,421.53 / $1,421.53 / $1,421.53
| Facility | | $1,421.53 | $1,421.53 | $1,421.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,421.53 / $1,663.34 / $2,077.98
| Professional | | $1,421.53 | $1,663.34 | $2,077.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,722.82 / $5,732.26 / $11,036.35
| Facility | | $2,722.82 | $5,732.26 | $11,036.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,185.61 / $3,329.98 / $5,044.93
| Professional | | $2,185.61 | $3,329.98 | $5,044.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,155.96 / $4,475.55 / $10,766.54
| Facility | | $3,155.96 | $4,475.55 | $10,766.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,561.48 / $4,168.82 / $6,045.82
| Professional | | $2,561.48 | $4,168.82 | $6,045.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,565.57 / $4,091.72 / $8,477.59
| Facility | | $2,565.57 | $4,091.72 | $8,477.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,140.60 / $3,435.66 / $5,114.31
| Professional | | $2,140.60 | $3,435.66 | $5,114.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,898.88 / $2,620.53 / $3,900.32
| Facility | | $1,898.88 | $2,620.53 | $3,900.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,734.22 / $2,959.76 / $5,849.60
| Professional | | $1,734.22 | $2,959.76 | $5,849.60 |
- 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
- $1,834.20 / $2,928.86 / $5,557.19
| Professional | | $1,834.20 | $2,928.86 | $5,557.19 |