- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,573.08 / $1,573.08 / $1,573.08
| Facility | | $1,573.08 | $1,573.08 | $1,573.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,573.08 / $1,855.79 / $2,338.17
| Professional | | $1,573.08 | $1,855.79 | $2,338.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,069.17 / $6,598.73 / $13,173.25
| Facility | | $3,069.17 | $6,598.73 | $13,173.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,460.52 / $3,753.56 / $5,686.66
| Professional | | $2,460.52 | $3,753.56 | $5,686.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,481.92 / $4,937.79 / $11,878.53
| Facility | | $3,481.92 | $4,937.79 | $11,878.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,822.53 / $4,593.67 / $6,661.96
| Professional | | $2,822.53 | $4,593.67 | $6,661.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,830.55 / $4,514.33 / $9,353.18
| Facility | | $2,830.55 | $4,514.33 | $9,353.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,358.75 / $3,785.79 / $5,635.51
| Professional | | $2,358.75 | $3,785.79 | $5,635.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,270.09 / $2,887.30 / $4,297.38
| Facility | | $2,270.09 | $2,887.30 | $4,297.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,000.53 / $3,339.87 / $6,559.65
| Professional | | $2,000.53 | $3,339.87 | $6,559.65 |
- 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
- $2,036.43 / $3,302.67 / $6,305.45
| Professional | | $2,036.43 | $3,302.67 | $6,305.45 |