- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,822.21 / $1,822.21 / $1,822.21
| Facility | | $1,822.21 | $1,822.21 | $1,822.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.21 / $1,907.74 / $2,668.29
| Professional | | $1,822.21 | $1,907.74 | $2,668.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,495.70 / $7,515.74 / $14,949.70
| Facility | | $3,495.70 | $7,515.74 | $14,949.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,805.87 / $4,275.20 / $6,476.95
| Professional | | $2,805.87 | $4,275.20 | $6,476.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,043.71 / $5,734.48 / $13,795.07
| Facility | | $4,043.71 | $5,734.48 | $13,795.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,280.71 / $5,339.37 / $7,743.40
| Professional | | $3,280.71 | $5,339.37 | $7,743.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,287.24 / $5,242.68 / $10,862.26
| Facility | | $3,287.24 | $5,242.68 | $10,862.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,741.65 / $4,400.35 / $6,550.33
| Professional | | $2,741.65 | $4,400.35 | $6,550.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.89 / $3,122.24 / $4,648.68
| Facility | | $2,424.89 | $3,122.24 | $4,648.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,224.82 / $3,806.60 / $7,518.48
| Professional | | $2,224.82 | $3,806.60 | $7,518.48 |
- 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
- $2,319.42 / $3,687.21 / $7,227.12
| Professional | | $2,319.42 | $3,687.21 | $7,227.12 |