- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,973.06 / $1,973.06 / $1,973.06
| Facility | | $1,973.06 | $1,973.06 | $1,973.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,973.06 / $1,980.05 / $2,863.42
| Professional | | $1,973.06 | $1,980.05 | $2,863.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,966.26 / $8,895.42 / $17,435.52
| Facility | | $3,966.26 | $8,895.42 | $17,435.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,384.75 / $5,237.47 / $7,362.65
| Professional | | $3,384.75 | $5,237.47 | $7,362.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,580.22 / $6,495.34 / $15,625.41
| Facility | | $4,580.22 | $6,495.34 | $15,625.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,713.07 / $6,262.32 / $8,908.16
| Professional | | $3,713.07 | $6,262.32 | $8,908.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,723.40 / $5,938.30 / $12,303.48
| Facility | | $3,723.40 | $5,938.30 | $12,303.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,269.01 / $5,594.25 / $7,413.57
| Professional | | $3,269.01 | $5,594.25 | $7,413.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,561.56 / $3,334.47 / $5,249.91
| Facility | | $2,561.56 | $3,334.47 | $5,249.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.53 / $5,077.10 / $10,917.50
| Professional | | $2,711.53 | $5,077.10 | $10,917.50 |
- 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
- $2,711.53 / $5,328.17 / $8,198.50
| Professional | | $2,711.53 | $5,328.17 | $8,198.50 |