- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,157.53 / $1,157.53 / $1,157.53
| Facility | | $1,157.53 | $1,157.53 | $1,157.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.53 / $1,265.48 / $2,109.16
| Professional | | $1,157.53 | $1,265.48 | $2,109.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,692.86 / $7,203.81 / $11,491.08
| Facility | | $3,692.86 | $7,203.81 | $11,491.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,211.06 / $3,752.82 / $4,551.63
| Professional | | $2,211.06 | $3,752.82 | $4,551.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,701.51 / $4,216.35 / $10,143.01
| Facility | | $2,701.51 | $4,216.35 | $10,143.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,144.71 / $3,833.13 / $5,270.09
| Professional | | $2,144.71 | $3,833.13 | $5,270.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,341.10 / $3,847.70 / $7,986.63
| Facility | | $2,341.10 | $3,847.70 | $7,986.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,124.67 / $3,497.11 / $4,818.42
| Professional | | $2,124.67 | $3,497.11 | $4,818.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,237.11 / $2,066.98 / $3,615.76
| Facility | | $1,237.11 | $2,066.98 | $3,615.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,490.52 / $2,936.16 / $9,351.44
| Professional | | $1,490.52 | $2,936.16 | $9,351.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $796.00 / $3,500.00 / $8,152.00
| Facility | | $796.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.50 / $2,731.29 / $5,012.10
| Professional | | $1,453.50 | $2,731.29 | $5,012.10 |