- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,393.43 / $1,393.43 / $1,393.43
| Facility | | $1,393.43 | $1,393.43 | $1,393.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.43 / $1,633.54 / $2,041.78
| Professional | | $1,393.43 | $1,633.54 | $2,041.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,651.18 / $5,700.05 / $11,371.04
| Facility | | $2,651.18 | $5,700.05 | $11,371.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,131.46 / $3,242.37 / $4,912.20
| Professional | | $2,131.46 | $3,242.37 | $4,912.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,078.47 / $4,365.66 / $10,502.19
| Facility | | $3,078.47 | $4,365.66 | $10,502.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,501.66 / $4,071.46 / $5,904.63
| Professional | | $2,501.66 | $4,071.46 | $5,904.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,502.58 / $3,991.26 / $8,269.44
| Facility | | $2,502.58 | $3,991.26 | $8,269.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,090.61 / $3,355.42 / $4,994.85
| Professional | | $2,090.61 | $3,355.42 | $4,994.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,719.36 / $2,558.76 / $3,808.38
| Facility | | $1,719.36 | $2,558.76 | $3,808.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.18 / $2,915.67 / $5,753.22
| Professional | | $1,583.18 | $2,915.67 | $5,753.22 |
- 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
- $1,714.84 / $3,100.62 / $5,530.26
| Professional | | $1,714.84 | $3,100.62 | $5,530.26 |