- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,982.72 / $1,982.72 / $1,982.72
| Facility | | $1,982.72 | $1,982.72 | $1,982.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,982.72 / $2,322.23 / $2,903.92
| Professional | | $1,982.72 | $2,322.23 | $2,903.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,805.90 / $8,013.17 / $15,722.08
| Facility | | $3,805.90 | $8,013.17 | $15,722.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,053.45 / $4,654.58 / $7,051.70
| Professional | | $3,053.45 | $4,654.58 | $7,051.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,400.83 / $6,240.92 / $15,013.38
| Facility | | $4,400.83 | $6,240.92 | $15,013.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,570.31 / $5,810.68 / $8,426.93
| Professional | | $3,570.31 | $5,810.68 | $8,426.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,577.56 / $5,705.70 / $11,821.56
| Facility | | $3,577.56 | $5,705.70 | $11,821.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,983.66 / $4,788.77 / $7,128.54
| Professional | | $2,983.66 | $4,788.77 | $7,128.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,641.10 / $3,378.00 / $5,058.14
| Facility | | $2,641.10 | $3,378.00 | $5,058.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,525.26 / $4,143.32 / $8,183.04
| Professional | | $2,525.26 | $4,143.32 | $8,183.04 |
- 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
- $2,730.00 / $4,885.25 / $7,865.92
| Professional | | $2,730.00 | $4,885.25 | $7,865.92 |