- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,438.46 / $1,438.46 / $1,438.46
| Facility | | $1,438.46 | $1,438.46 | $1,438.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,438.46 / $1,538.83 / $2,239.44
| Professional | | $1,438.46 | $1,538.83 | $2,239.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,106.63 / $6,863.77 / $13,453.37
| Facility | | $3,106.63 | $6,863.77 | $13,453.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,660.69 / $4,117.35 / $5,771.62
| Professional | | $2,660.69 | $4,117.35 | $5,771.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,611.63 / $5,121.74 / $12,321.03
| Facility | | $3,611.63 | $5,121.74 | $12,321.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,937.42 / $4,938.00 / $7,047.27
| Professional | | $2,937.42 | $4,938.00 | $7,047.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,935.99 / $4,682.50 / $9,701.60
| Facility | | $2,935.99 | $4,682.50 | $9,701.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,586.12 / $4,425.62 / $5,864.89
| Professional | | $2,586.12 | $4,425.62 | $5,864.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,897.53 / $2,586.10 / $3,784.67
| Facility | | $1,897.53 | $2,586.10 | $3,784.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,005.32 / $3,949.25 / $7,928.51
| Professional | | $2,005.32 | $3,949.25 | $7,928.51 |
- 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
- $2,092.76 / $3,906.30 / $6,992.69
| Professional | | $2,092.76 | $3,906.30 | $6,992.69 |