- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,734.05 / $1,734.05 / $1,734.05
| Facility | | $1,734.05 | $1,734.05 | $1,734.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,697.85 / $1,765.32 / $2,766.36
| Professional | | $1,697.85 | $1,765.32 | $2,766.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,088.76 / $5,302.71 / $13,254.92
| Facility | | $2,088.76 | $5,302.71 | $13,254.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.08 / $4,950.26 / $6,292.80
| Professional | | $3,081.08 | $4,950.26 | $6,292.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,201.57 / $5,961.43 / $14,341.01
| Facility | | $4,201.57 | $5,961.43 | $14,341.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,150.53 / $5,018.72 / $7,453.57
| Professional | | $3,150.53 | $5,018.72 | $7,453.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,819.61 / $5,450.17 / $11,292.14
| Facility | | $3,819.61 | $5,450.17 | $11,292.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,852.39 / $4,487.08 / $6,835.36
| Professional | | $2,852.39 | $4,487.08 | $6,835.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,831.00 / $3,257.76 / $4,886.64
| Facility | | $1,831.00 | $3,257.76 | $4,886.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,930.62 / $3,510.22 / $6,997.49
| Professional | | $1,930.62 | $3,510.22 | $6,997.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,412.00 / $4,746.00 / $8,812.00
| Facility | | $2,412.00 | $4,746.00 | $8,812.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,904.71 / $3,431.24 / $6,931.56
| Professional | | $1,904.71 | $3,431.24 | $6,931.56 |