- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,438.17 / $1,438.17 / $1,438.17
| Facility | | $1,438.17 | $1,438.17 | $1,438.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,438.17 / $1,696.83 / $2,138.13
| Professional | | $1,438.17 | $1,696.83 | $2,138.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,142.55 / $8,245.37 / $13,050.54
| Facility | | $4,142.55 | $8,245.37 | $13,050.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,249.21 / $3,433.66 / $5,202.01
| Professional | | $2,249.21 | $3,433.66 | $5,202.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,183.76 / $4,514.96 / $10,861.36
| Facility | | $3,183.76 | $4,514.96 | $10,861.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,579.16 / $4,197.59 / $6,087.54
| Professional | | $2,579.16 | $4,197.59 | $6,087.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,588.17 / $4,127.76 / $8,552.25
| Facility | | $2,588.17 | $4,127.76 | $8,552.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,155.37 / $3,459.37 / $5,149.60
| Professional | | $2,155.37 | $3,459.37 | $5,149.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.27 / $2,638.63 / $3,954.00
| Facility | | $1,584.27 | $2,638.63 | $3,954.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.68 / $3,058.67 / $6,007.20
| Professional | | $1,854.68 | $3,058.67 | $6,007.20 |
- 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
- $1,854.68 / $3,002.84 / $5,774.40
| Professional | | $1,854.68 | $3,002.84 | $5,774.40 |