- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,635.03 / $1,635.03 / $1,635.03
| Facility | | $1,635.03 | $1,635.03 | $1,635.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.03 / $1,692.68 / $2,430.52
| Professional | | $1,635.03 | $1,692.68 | $2,430.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,190.76 / $6,860.12 / $13,662.42
| Facility | | $3,190.76 | $6,860.12 | $13,662.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,558.29 / $3,957.56 / $5,911.93
| Professional | | $2,558.29 | $3,957.56 | $5,911.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,619.21 / $5,132.49 / $12,346.89
| Facility | | $3,619.21 | $5,132.49 | $12,346.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,934.02 / $4,775.10 / $6,925.10
| Professional | | $2,934.02 | $4,775.10 | $6,925.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,942.16 / $4,692.32 / $9,721.95
| Facility | | $2,942.16 | $4,692.32 | $9,721.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,451.92 / $3,935.33 / $5,858.11
| Professional | | $2,451.92 | $3,935.33 | $5,858.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,343.96 / $3,001.49 / $4,480.07
| Facility | | $2,343.96 | $3,001.49 | $4,480.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.10 / $3,475.70 / $6,826.34
| Professional | | $2,117.10 | $3,475.70 | $6,826.34 |
- 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
- $2,149.42 / $3,437.05 / $6,561.79
| Professional | | $2,149.42 | $3,437.05 | $6,561.79 |