- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.12 / $1,548.12 / $1,548.12
| Facility | | $1,548.12 | $1,548.12 | $1,548.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.12 / $1,658.29 / $2,396.19
| Professional | | $1,548.12 | $1,658.29 | $2,396.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,041.50 / $7,219.65 / $14,477.85
| Facility | | $3,041.50 | $7,219.65 | $14,477.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,750.06 / $4,239.45 / $5,948.46
| Professional | | $2,750.06 | $4,239.45 | $5,948.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,924.11 / $5,564.87 / $13,387.05
| Facility | | $3,924.11 | $5,564.87 | $13,387.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,190.30 / $5,365.23 / $7,653.97
| Professional | | $3,190.30 | $5,365.23 | $7,653.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,190.02 / $5,087.63 / $10,540.99
| Facility | | $3,190.02 | $5,087.63 | $10,540.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,808.76 / $4,806.63 / $6,369.81
| Professional | | $2,808.76 | $4,806.63 | $6,369.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,122.34 / $2,808.47 / $4,386.50
| Facility | | $2,122.34 | $2,808.47 | $4,386.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,135.21 / $4,293.21 / $8,619.03
| Professional | | $2,135.21 | $4,293.21 | $8,619.03 |
- 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
- $2,357.83 / $4,599.35 / $6,659.22
| Professional | | $2,357.83 | $4,599.35 | $6,659.22 |