- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,073.86 / $1,073.86 / $1,073.86
| Facility | | $1,073.86 | $1,073.86 | $1,073.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.86 / $1,143.46 / $1,659.84
| Professional | | $1,073.86 | $1,143.46 | $1,659.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,647.11 / $5,829.32 / $9,712.56
| Facility | | $2,647.11 | $5,829.32 | $9,712.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,906.41 / $2,940.28 / $4,125.57
| Professional | | $1,906.41 | $2,940.28 | $4,125.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,724.72 / $3,864.00 / $9,295.37
| Facility | | $2,724.72 | $3,864.00 | $9,295.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,214.79 / $3,725.38 / $5,313.58
| Professional | | $2,214.79 | $3,725.38 | $5,313.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,215.00 / $3,532.62 / $7,319.19
| Facility | | $2,215.00 | $3,532.62 | $7,319.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.91 / $3,336.88 / $4,422.08
| Professional | | $1,949.91 | $3,336.88 | $4,422.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,514.98 / $1,949.51 / $3,378.00
| Facility | | $1,514.98 | $1,949.51 | $3,378.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,477.39 / $2,962.57 / $5,947.64
| Professional | | $1,477.39 | $2,962.57 | $5,947.64 |
- 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
- $1,499.95 / $3,453.72 / $4,585.95
| Professional | | $1,499.95 | $3,453.72 | $4,585.95 |