- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,974.56 / $1,974.56 / $1,974.56
| Facility | | $1,974.56 | $1,974.56 | $1,974.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,974.56 / $2,319.11 / $2,908.22
| Professional | | $1,974.56 | $2,319.11 | $2,908.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,806.56 / $8,184.12 / $16,420.08
| Facility | | $3,806.56 | $8,184.12 | $16,420.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,048.71 / $4,635.34 / $7,052.92
| Professional | | $3,048.71 | $4,635.34 | $7,052.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,368.82 / $6,195.53 / $14,904.20
| Facility | | $4,368.82 | $6,195.53 | $14,904.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,538.36 / $5,758.68 / $8,351.52
| Professional | | $3,538.36 | $5,758.68 | $8,351.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,551.54 / $5,664.20 / $11,735.59
| Facility | | $3,551.54 | $5,664.20 | $11,735.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,956.96 / $4,745.92 / $7,064.75
| Professional | | $2,956.96 | $4,745.92 | $7,064.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,650.14 / $3,367.44 / $5,040.54
| Facility | | $2,650.14 | $3,367.44 | $5,040.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.48 / $4,166.10 / $8,211.15
| Professional | | $2,429.48 | $4,166.10 | $8,211.15 |
- 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
- $2,564.25 / $4,500.29 / $7,892.94
| Professional | | $2,564.25 | $4,500.29 | $7,892.94 |