- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,051.63 / $1,051.63 / $1,051.63
| Facility | | $1,051.63 | $1,051.63 | $1,051.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.63 / $1,181.41 / $1,414.15
| Professional | | $1,051.63 | $1,181.41 | $1,414.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,045.81 / $6,699.65 / $12,643.17
| Facility | | $4,045.81 | $6,699.65 | $12,643.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,958.44 / $3,047.02 / $4,275.34
| Professional | | $1,958.44 | $3,047.02 | $4,275.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,783.68 / $3,947.61 / $9,496.50
| Facility | | $2,783.68 | $3,947.61 | $9,496.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,241.98 / $3,805.99 / $5,378.82
| Professional | | $2,241.98 | $3,805.99 | $5,378.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,262.92 / $3,609.06 / $7,477.56
| Facility | | $2,262.92 | $3,609.06 | $7,477.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,973.85 / $3,377.85 / $4,476.38
| Professional | | $1,973.85 | $3,377.85 | $4,476.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,539.66 / $2,292.98 / $7,729.00
| Facility | | $1,539.66 | $2,292.98 | $7,729.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,605.68 / $2,987.62 / $6,424.40
| Professional | | $1,605.68 | $2,987.62 | $6,424.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,735.00 / $4,974.00 / $8,812.00
| Facility | | $2,735.00 | $4,974.00 | $8,812.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.91 / $2,750.71 / $4,606.53
| Professional | | $1,544.91 | $2,750.71 | $4,606.53 |