- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,898.86 / $1,898.86 / $1,898.86
| Facility | | $1,898.86 | $1,898.86 | $1,898.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,898.86 / $2,227.48 / $2,789.95
| Professional | | $1,898.86 | $2,227.48 | $2,789.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,652.11 / $7,852.04 / $15,702.06
| Facility | | $3,652.11 | $7,852.04 | $15,702.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,928.86 / $4,466.50 / $6,766.76
| Professional | | $2,928.86 | $4,466.50 | $6,766.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,206.27 / $5,965.01 / $14,349.63
| Facility | | $4,206.27 | $5,965.01 | $14,349.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,409.88 / $5,549.58 / $8,048.26
| Professional | | $3,409.88 | $5,549.58 | $8,048.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,419.39 / $5,453.45 / $11,298.93
| Facility | | $3,419.39 | $5,453.45 | $11,298.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,849.59 / $4,573.59 / $6,808.22
| Professional | | $2,849.59 | $4,573.59 | $6,808.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,432.17 / $3,245.24 / $4,719.08
| Facility | | $2,432.17 | $3,245.24 | $4,719.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,330.63 / $3,989.70 / $7,870.55
| Professional | | $2,330.63 | $3,989.70 | $7,870.55 |
- 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
- $2,423.21 / $4,313.62 / $7,565.54
| Professional | | $2,423.21 | $4,313.62 | $7,565.54 |