- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,038.72 / $1,038.72 / $1,038.72
| Facility | | $1,038.72 | $1,038.72 | $1,038.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,038.72 / $1,105.43 / $1,605.17
| Professional | | $1,038.72 | $1,105.43 | $1,605.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,038.46 / $4,812.62 / $11,773.06
| Facility | | $2,038.46 | $4,812.62 | $11,773.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,843.13 / $2,841.34 / $3,986.75
| Professional | | $1,843.13 | $2,841.34 | $3,986.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,634.60 / $3,736.19 / $8,987.92
| Facility | | $2,634.60 | $3,736.19 | $8,987.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,142.05 / $3,602.16 / $5,139.07
| Professional | | $2,142.05 | $3,602.16 | $5,139.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,141.73 / $3,415.78 / $7,077.10
| Facility | | $2,141.73 | $3,415.78 | $7,077.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.87 / $3,227.29 / $4,276.85
| Professional | | $1,885.87 | $3,227.29 | $4,276.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.45 / $1,885.43 / $3,378.00
| Facility | | $1,479.45 | $1,885.43 | $3,378.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,439.14 / $2,863.96 / $5,749.66
| Professional | | $1,439.14 | $2,863.96 | $5,749.66 |
- 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
- $1,449.47 / $2,636.86 / $4,415.85
| Professional | | $1,449.47 | $2,636.86 | $4,415.85 |