- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,321.61 / $1,321.61 / $1,321.61
| Facility | | $1,321.61 | $1,321.61 | $1,321.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,298.92 / $1,439.98 / $2,395.77
| Professional | | $1,298.92 | $1,439.98 | $2,395.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,527.12 / $3,895.97 / $11,000.97
| Facility | | $1,527.12 | $3,895.97 | $11,000.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,510.71 / $4,256.74 / $5,162.81
| Professional | | $2,510.71 | $4,256.74 | $5,162.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,074.21 / $4,798.05 / $11,542.35
| Facility | | $3,074.21 | $4,798.05 | $11,542.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,420.92 / $4,367.60 / $6,004.93
| Professional | | $2,420.92 | $4,367.60 | $6,004.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,664.07 / $4,378.53 / $9,088.45
| Facility | | $2,664.07 | $4,378.53 | $9,088.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,420.92 / $3,984.73 / $5,490.28
| Professional | | $2,420.92 | $3,984.73 | $5,490.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,391.68 / $2,355.53 / $4,101.22
| Facility | | $1,391.68 | $2,355.53 | $4,101.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.15 / $3,343.11 / $10,590.72
| Professional | | $1,653.15 | $3,343.11 | $10,590.72 |
- 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
- $1,591.35 / $3,024.71 / $5,706.78
| Professional | | $1,591.35 | $3,024.71 | $5,706.78 |