- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,571.44 / $1,571.44 / $1,571.44
| Facility | | $1,571.44 | $1,571.44 | $1,571.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,571.44 / $1,767.43 / $2,889.21
| Professional | | $1,571.44 | $1,767.43 | $2,889.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,511.39 / $9,185.09 / $16,508.77
| Facility | | $4,511.39 | $9,185.09 | $16,508.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,939.78 / $4,531.91 / $6,358.83
| Professional | | $2,939.78 | $4,531.91 | $6,358.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,193.63 / $5,947.09 / $14,306.53
| Facility | | $4,193.63 | $5,947.09 | $14,306.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,409.20 / $5,733.74 / $8,179.13
| Professional | | $3,409.20 | $5,733.74 | $8,179.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,409.12 / $5,437.07 / $11,264.99
| Facility | | $3,409.12 | $5,437.07 | $11,264.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,001.48 / $5,136.42 / $6,806.86
| Professional | | $3,001.48 | $5,136.42 | $6,806.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.92 / $3,001.29 / $4,713.52
| Facility | | $2,283.92 | $3,001.29 | $4,713.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,288.36 / $4,577.64 / $7,093.44
| Professional | | $2,288.36 | $4,577.64 | $7,093.44 |
- 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
- $2,288.36 / $4,355.14 / $7,058.16
| Professional | | $2,288.36 | $4,355.14 | $7,058.16 |