- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,043.56 / $2,043.56 / $2,043.56
| Facility | | $2,043.56 | $2,043.56 | $2,043.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,043.56 / $2,132.73 / $3,001.71
| Professional | | $2,043.56 | $2,132.73 | $3,001.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,918.28 / $8,424.32 / $16,814.84
| Facility | | $3,918.28 | $8,424.32 | $16,814.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,145.43 / $4,792.02 / $7,259.93
| Professional | | $3,145.43 | $4,792.02 | $7,259.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,529.70 / $6,423.67 / $15,453.01
| Facility | | $4,529.70 | $6,423.67 | $15,453.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,677.72 / $5,985.49 / $8,680.44
| Professional | | $3,677.72 | $5,985.49 | $8,680.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,682.32 / $5,872.78 / $12,167.73
| Facility | | $3,682.32 | $5,872.78 | $12,167.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,073.42 / $4,932.84 / $7,342.99
| Professional | | $3,073.42 | $4,932.84 | $7,342.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,229.26 / $3,453.62 / $5,072.97
| Facility | | $2,229.26 | $3,453.62 | $5,072.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,515.85 / $4,306.21 / $8,492.45
| Professional | | $2,515.85 | $4,306.21 | $8,492.45 |
- 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
- $2,515.85 / $4,654.46 / $8,163.35
| Professional | | $2,515.85 | $4,654.46 | $8,163.35 |