- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,147.92 / $2,147.92 / $2,147.92
| Facility | | $2,147.92 | $2,147.92 | $2,147.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.92 / $2,242.51 / $3,002.74
| Professional | | $2,147.92 | $2,242.51 | $3,002.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,184.29 / $9,733.60 / $17,904.59
| Facility | | $4,184.29 | $9,733.60 | $17,904.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,421.68 / $5,308.64 / $7,448.67
| Professional | | $3,421.68 | $5,308.64 | $7,448.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,977.78 / $7,059.11 / $16,981.65
| Facility | | $4,977.78 | $7,059.11 | $16,981.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,017.62 / $6,805.87 / $9,638.82
| Professional | | $4,017.62 | $6,805.87 | $9,638.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,046.58 / $6,453.72 / $13,371.38
| Facility | | $4,046.58 | $6,453.72 | $13,371.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,537.14 / $6,053.09 / $8,021.64
| Professional | | $3,537.14 | $6,053.09 | $8,021.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,341.36 / $3,536.85 / $4,772.81
| Facility | | $2,341.36 | $3,536.85 | $4,772.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,702.47 / $5,337.40 / $11,477.24
| Professional | | $2,702.47 | $5,337.40 | $11,477.24 |
- 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
- $2,702.47 / $4,914.17 / $8,618.84
| Professional | | $2,702.47 | $4,914.17 | $8,618.84 |