- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,708.42 / $1,708.42 / $1,708.42
| Facility | | $1,708.42 | $1,708.42 | $1,708.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.42 / $1,717.53 / $2,481.66
| Professional | | $1,708.42 | $1,717.53 | $2,481.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,433.93 / $7,673.13 / $15,039.75
| Facility | | $3,433.93 | $7,673.13 | $15,039.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,932.63 / $4,534.52 / $6,362.48
| Professional | | $2,932.63 | $4,534.52 | $6,362.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,962.01 / $5,618.62 / $13,516.36
| Facility | | $3,962.01 | $5,618.62 | $13,516.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,213.41 / $5,417.06 / $7,709.43
| Professional | | $3,213.41 | $5,417.06 | $7,709.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,220.83 / $5,136.77 / $10,642.80
| Facility | | $3,220.83 | $5,136.77 | $10,642.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,829.11 / $4,841.45 / $6,415.96
| Professional | | $2,829.11 | $4,841.45 | $6,415.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,097.00 / $3,057.86 / $4,586.79
| Facility | | $2,097.00 | $3,057.86 | $4,586.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,354.88 / $4,403.13 / $9,468.25
| Professional | | $2,354.88 | $4,403.13 | $9,468.25 |
- 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
- $2,313.23 / $4,189.12 / $7,151.96
| Professional | | $2,313.23 | $4,189.12 | $7,151.96 |