- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,137.63 / $1,137.63 / $1,137.63
| Facility | | $1,137.63 | $1,137.63 | $1,137.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,137.63 / $1,212.31 / $1,759.46
| Professional | | $1,137.63 | $1,212.31 | $1,759.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,647.11 / $5,993.36 / $10,295.31
| Facility | | $2,647.11 | $5,993.36 | $10,295.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,020.46 / $3,113.10 / $4,370.33
| Professional | | $2,020.46 | $3,113.10 | $4,370.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,885.60 / $4,092.13 / $9,844.18
| Facility | | $2,885.60 | $4,092.13 | $9,844.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,345.98 / $3,945.33 / $5,628.35
| Professional | | $2,345.98 | $3,945.33 | $5,628.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,345.78 / $3,741.19 / $7,751.33
| Facility | | $2,345.78 | $3,741.19 | $7,751.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,065.42 / $3,534.56 / $4,684.04
| Professional | | $2,065.42 | $3,534.56 | $4,684.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,506.61 / $2,065.21 / $3,500.00
| Facility | | $1,506.61 | $2,065.21 | $3,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.04 / $3,140.63 / $6,305.12
| Professional | | $1,565.04 | $3,140.63 | $6,305.12 |
- 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
- $1,588.94 / $3,140.63 / $4,863.18
| Professional | | $1,588.94 | $3,140.63 | $4,863.18 |