- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,404.07 / $1,404.07 / $1,404.07
| Facility | | $1,404.07 | $1,404.07 | $1,404.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.07 / $1,644.33 / $2,054.89
| Professional | | $1,404.07 | $1,644.33 | $2,054.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,686.02 / $5,774.95 / $11,448.28
| Facility | | $2,686.02 | $5,774.95 | $11,448.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.71 / $3,284.97 / $4,976.74
| Professional | | $2,146.71 | $3,284.97 | $4,976.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,118.90 / $4,422.99 / $10,640.11
| Facility | | $3,118.90 | $4,422.99 | $10,640.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,515.26 / $4,093.59 / $5,936.72
| Professional | | $2,515.26 | $4,093.59 | $5,936.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,535.44 / $4,043.68 / $8,378.04
| Facility | | $2,535.44 | $4,043.68 | $8,378.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,101.96 / $3,373.66 / $5,022.01
| Professional | | $2,101.96 | $3,373.66 | $5,022.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,846.11 / $2,573.03 / $3,829.63
| Facility | | $1,846.11 | $2,573.03 | $3,829.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.27 / $2,923.40 / $5,772.92
| Professional | | $1,715.27 | $2,923.40 | $5,772.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.00 / $3,236.00 / $5,530.00
| Facility | | $1,445.00 | $3,236.00 | $5,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.27 / $2,891.13 / $5,484.34
| Professional | | $1,715.27 | $2,891.13 | $5,484.34 |