- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,307.91 / $1,307.91 / $1,307.91
| Facility | | $1,307.91 | $1,307.91 | $1,307.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.91 / $1,542.07 / $1,941.68
| Professional | | $1,307.91 | $1,542.07 | $1,941.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,549.96 / $5,482.44 / $10,927.64
| Facility | | $2,549.96 | $5,482.44 | $10,927.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.74 / $3,162.78 / $4,724.68
| Professional | | $2,044.74 | $3,162.78 | $4,724.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,896.55 / $4,107.66 / $9,881.54
| Facility | | $2,896.55 | $4,107.66 | $9,881.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,348.71 / $3,822.53 / $5,543.61
| Professional | | $2,348.71 | $3,822.53 | $5,543.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,354.67 / $3,755.39 / $7,780.74
| Facility | | $2,354.67 | $3,755.39 | $7,780.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,962.79 / $3,150.27 / $4,689.47
| Professional | | $1,962.79 | $3,150.27 | $4,689.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,908.38 / $2,402.82 / $3,577.76
| Facility | | $1,908.38 | $2,402.82 | $3,577.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,734.26 / $2,884.04 / $5,446.03
| Professional | | $1,734.26 | $2,884.04 | $5,446.03 |
- 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
- $1,878.79 / $3,208.23 / $5,234.97
| Professional | | $1,878.79 | $3,208.23 | $5,234.97 |