- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,775.56 / $2,775.56 / $2,775.56
| Facility | | $2,775.56 | $2,775.56 | $2,775.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,775.56 / $3,251.20 / $4,066.11
| Professional | | $2,775.56 | $3,251.20 | $4,066.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,324.71 / $11,448.13 / $22,704.90
| Facility | | $5,324.71 | $11,448.13 | $22,704.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,268.20 / $6,512.06 / $9,865.81
| Professional | | $4,268.20 | $6,512.06 | $9,865.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,153.58 / $8,726.54 / $20,992.88
| Facility | | $6,153.58 | $8,726.54 | $20,992.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,987.68 / $8,117.47 / $11,772.35
| Professional | | $4,987.68 | $8,117.47 | $11,772.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,002.42 / $7,978.15 / $16,529.83
| Facility | | $5,002.42 | $7,978.15 | $16,529.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.14 / $6,689.88 / $9,958.51
| Professional | | $4,168.14 | $6,689.88 | $9,958.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,441.18 / $4,392.56 / $6,871.73
| Facility | | $3,441.18 | $4,392.56 | $6,871.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,366.73 / $5,788.76 / $11,430.77
| Professional | | $3,366.73 | $5,788.76 | $11,430.77 |
- 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
- $3,586.94 / $6,264.86 / $11,430.77
| Professional | | $3,586.94 | $6,264.86 | $11,430.77 |