- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,453.65 / $1,453.65 / $1,453.65
| Facility | | $1,453.65 | $1,453.65 | $1,453.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.65 / $1,709.72 / $2,147.34
| Professional | | $1,453.65 | $1,709.72 | $2,147.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,799.72 / $6,019.39 / $12,114.81
| Facility | | $2,799.72 | $6,019.39 | $12,114.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,231.34 / $3,424.02 / $5,187.39
| Professional | | $2,231.34 | $3,424.02 | $5,187.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,197.23 / $4,534.08 / $10,907.33
| Facility | | $3,197.23 | $4,534.08 | $10,907.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,577.80 / $4,195.37 / $6,084.33
| Professional | | $2,577.80 | $4,195.37 | $6,084.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,599.12 / $4,145.22 / $8,588.45
| Facility | | $2,599.12 | $4,145.22 | $8,588.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,154.23 / $3,457.55 / $5,146.88
| Professional | | $2,154.23 | $3,457.55 | $5,146.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,058.73 / $2,636.95 / $3,924.77
| Facility | | $2,058.73 | $2,636.95 | $3,924.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.11 / $3,057.94 / $6,019.24
| Professional | | $1,808.11 | $3,057.94 | $6,019.24 |
- 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
- $1,886.01 / $3,408.93 / $5,718.35
| Professional | | $1,886.01 | $3,408.93 | $5,718.35 |