- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,110.57 / $2,110.57 / $2,110.57
| Facility | | $2,110.57 | $2,110.57 | $2,110.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,110.57 / $2,476.62 / $3,102.90
| Professional | | $2,110.57 | $2,476.62 | $3,102.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,062.87 / $8,735.18 / $17,481.37
| Facility | | $4,062.87 | $8,735.18 | $17,481.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,516.92 / $5,070.79 / $7,980.96
| Professional | | $3,516.92 | $5,070.79 | $7,980.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,674.57 / $6,629.11 / $15,947.23
| Facility | | $4,674.57 | $6,629.11 | $15,947.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,788.53 / $6,165.83 / $8,941.98
| Professional | | $3,788.53 | $6,165.83 | $8,941.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,800.09 / $6,060.60 / $12,556.88
| Facility | | $3,800.09 | $6,060.60 | $12,556.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,166.02 / $5,081.46 / $7,564.23
| Professional | | $3,166.02 | $5,081.46 | $7,564.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,847.42 / $3,566.86 / $5,769.15
| Facility | | $2,847.42 | $3,566.86 | $5,769.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,695.76 / $4,440.10 / $8,757.12
| Professional | | $2,695.76 | $4,440.10 | $8,757.12 |
- 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
- $2,736.91 / $4,799.52 / $8,417.76
| Professional | | $2,736.91 | $4,799.52 | $8,417.76 |