- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,823.62 / $1,823.62 / $1,823.62
| Facility | | $1,823.62 | $1,823.62 | $1,823.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,823.62 / $2,135.14 / $2,669.08
| Professional | | $1,823.62 | $2,135.14 | $2,669.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.36 / $7,517.18 / $14,941.13
| Facility | | $3,496.36 | $7,517.18 | $14,941.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,806.39 / $4,276.00 / $6,478.16
| Professional | | $2,806.39 | $4,276.00 | $6,478.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,047.08 / $5,739.26 / $13,806.57
| Facility | | $4,047.08 | $5,739.26 | $13,806.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,284.11 / $5,344.90 / $7,751.43
| Professional | | $3,284.11 | $5,344.90 | $7,751.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,289.98 / $5,247.06 / $10,871.31
| Facility | | $3,289.98 | $5,247.06 | $10,871.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,744.49 / $4,404.91 / $6,557.12
| Professional | | $2,744.49 | $4,404.91 | $6,557.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,409.17 / $3,125.02 / $4,625.52
| Facility | | $2,409.17 | $3,125.02 | $4,625.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.39 / $3,804.92 / $7,516.47
| Professional | | $2,225.39 | $3,804.92 | $7,516.47 |
- 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
- $2,225.39 / $3,684.37 / $7,225.18
| Professional | | $2,225.39 | $3,684.37 | $7,225.18 |