- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,482.42 / $1,482.42 / $1,482.42
| Facility | | $1,482.42 | $1,482.42 | $1,482.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.42 / $1,735.59 / $2,166.62
| Professional | | $1,482.42 | $1,735.59 | $2,166.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,817.46 / $6,057.54 / $12,103.37
| Facility | | $2,817.46 | $6,057.54 | $12,103.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,264.46 / $3,445.72 / $5,220.28
| Professional | | $2,264.46 | $3,445.72 | $5,220.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,281.46 / $4,653.52 / $11,194.67
| Facility | | $3,281.46 | $4,653.52 | $11,194.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,666.18 / $4,339.20 / $6,292.92
| Professional | | $2,666.18 | $4,339.20 | $6,292.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,667.59 / $4,254.43 / $8,814.70
| Facility | | $2,667.59 | $4,254.43 | $8,814.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,228.09 / $3,576.08 / $5,323.33
| Professional | | $2,228.09 | $3,576.08 | $5,323.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,945.87 / $2,728.01 / $3,954.00
| Facility | | $1,945.87 | $2,728.01 | $3,954.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.19 / $3,084.39 / $6,091.80
| Professional | | $1,812.19 | $3,084.39 | $6,091.80 |
- 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
- $1,956.70 / $3,642.00 / $5,855.73
| Professional | | $1,956.70 | $3,642.00 | $5,855.73 |