- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.08 / $1,116.08 / $1,116.08
| Facility | | $1,116.08 | $1,116.08 | $1,116.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.08 / $1,188.52 / $1,725.78
| Professional | | $1,116.08 | $1,188.52 | $1,725.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,647.11 / $5,923.26 / $10,098.12
| Facility | | $2,647.11 | $5,923.26 | $10,098.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,982.18 / $3,055.70 / $4,287.52
| Professional | | $1,982.18 | $3,055.70 | $4,287.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,830.85 / $4,014.50 / $9,657.41
| Facility | | $2,830.85 | $4,014.50 | $9,657.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,301.80 / $3,870.48 / $5,522.34
| Professional | | $2,301.80 | $3,870.48 | $5,522.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,301.28 / $3,670.21 / $7,604.26
| Facility | | $2,301.28 | $3,670.21 | $7,604.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,026.52 / $3,467.98 / $4,595.82
| Professional | | $2,026.52 | $3,467.98 | $4,595.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,588.04 / $2,026.12 / $3,500.00
| Facility | | $1,588.04 | $2,026.12 | $3,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,587.14 / $3,079.16 / $6,181.72
| Professional | | $1,587.14 | $3,079.16 | $6,181.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.00 / $3,236.00 / $5,530.00
| Facility | | $1,445.00 | $3,236.00 | $5,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,582.27 / $3,298.29 / $4,767.06
| Professional | | $1,582.27 | $3,298.29 | $4,767.06 |