- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,579.11 / $1,579.11 / $1,579.11
| Facility | | $1,579.11 | $1,579.11 | $1,579.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,579.11 / $1,859.08 / $2,333.48
| Professional | | $1,579.11 | $1,859.08 | $2,333.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,027.76 / $6,509.69 / $13,236.18
| Facility | | $3,027.76 | $6,509.69 | $13,236.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,427.92 / $3,613.24 / $5,609.94
| Professional | | $2,427.92 | $3,613.24 | $5,609.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,478.55 / $4,933.02 / $11,867.04
| Facility | | $3,478.55 | $4,933.02 | $11,867.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,820.49 / $4,590.35 / $6,657.15
| Professional | | $2,820.49 | $4,590.35 | $6,657.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,827.81 / $4,509.96 / $9,344.12
| Facility | | $2,827.81 | $4,509.96 | $9,344.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,357.05 / $3,783.06 / $5,631.44
| Professional | | $2,357.05 | $3,783.06 | $5,631.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,745.06 / $2,885.17 / $3,954.00
| Facility | | $1,745.06 | $2,885.17 | $3,954.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.52 / $3,351.68 / $6,592.89
| Professional | | $1,828.52 | $3,351.68 | $6,592.89 |
- 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
- $1,980.59 / $3,259.75 / $6,337.40
| Professional | | $1,980.59 | $3,259.75 | $6,337.40 |