- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.34 / $1,380.34 / $1,380.34
| Facility | | $1,380.34 | $1,380.34 | $1,380.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.34 / $1,627.77 / $2,050.03
| Professional | | $1,380.34 | $1,627.77 | $2,050.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $988.21 / $2,110.42 / $10,323.75
| Facility | | $988.21 | $2,110.42 | $10,323.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,158.28 / $3,290.59 / $4,985.26
| Professional | | $2,158.28 | $3,290.59 | $4,985.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,056.58 / $4,334.60 / $10,427.48
| Facility | | $3,056.58 | $4,334.60 | $10,427.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,477.87 / $4,032.74 / $5,848.47
| Professional | | $2,477.87 | $4,032.74 | $5,848.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,484.78 / $3,962.87 / $8,210.61
| Facility | | $2,484.78 | $3,962.87 | $8,210.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,070.71 / $3,323.51 / $4,947.35
| Professional | | $2,070.71 | $3,323.51 | $4,947.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,031.62 / $2,534.96 / $3,805.65
| Facility | | $2,031.62 | $2,534.96 | $3,805.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,745.38 / $2,927.21 / $5,750.85
| Professional | | $1,745.38 | $2,927.21 | $5,750.85 |
- 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
- $1,812.51 / $3,151.87 / $5,750.85
| Professional | | $1,812.51 | $3,151.87 | $5,750.85 |