- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,022.93 / $2,022.93 / $2,022.93
| Facility | | $2,022.93 | $2,022.93 | $2,022.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,022.93 / $2,466.53 / $7,245.92
| Professional | | $2,022.93 | $2,466.53 | $7,245.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,887.40 / $8,274.15 / $16,234.13
| Facility | | $3,887.40 | $8,274.15 | $16,234.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,118.10 / $4,754.24 / $7,202.70
| Professional | | $3,118.10 | $4,754.24 | $7,202.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,484.21 / $6,359.17 / $15,297.85
| Facility | | $4,484.21 | $6,359.17 | $15,297.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,636.25 / $5,918.00 / $8,582.57
| Professional | | $3,636.25 | $5,918.00 | $8,582.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,645.34 / $5,813.81 / $12,045.55
| Facility | | $3,645.34 | $5,813.81 | $12,045.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,038.77 / $4,877.22 / $7,260.20
| Professional | | $3,038.77 | $4,877.22 | $7,260.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,611.83 / $3,418.75 / $5,016.39
| Facility | | $2,611.83 | $3,418.75 | $5,016.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,474.88 / $4,238.60 / $8,365.25
| Professional | | $2,474.88 | $4,238.60 | $8,365.25 |
- 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
- $2,618.71 / $4,192.28 / $7,947.08
| Professional | | $2,618.71 | $4,192.28 | $7,947.08 |