- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,365.03 / $2,365.03 / $2,365.03
| Facility | | $2,365.03 | $2,365.03 | $2,365.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,365.03 / $2,774.14 / $3,474.26
| Professional | | $2,365.03 | $2,774.14 | $3,474.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,550.52 / $9,783.61 / $19,538.18
| Facility | | $4,550.52 | $9,783.61 | $19,538.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,646.89 / $5,565.23 / $8,431.35
| Professional | | $3,646.89 | $5,565.23 | $8,431.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,239.72 / $7,430.58 / $17,875.27
| Facility | | $5,239.72 | $7,430.58 | $17,875.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,246.71 / $6,911.52 / $10,023.42
| Professional | | $4,246.71 | $6,911.52 | $10,023.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,259.52 / $6,793.33 / $14,075.01
| Facility | | $4,259.52 | $6,793.33 | $14,075.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.92 / $5,696.01 / $8,479.04
| Professional | | $3,548.92 | $5,696.01 | $8,479.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,139.58 / $3,745.69 / $6,085.52
| Facility | | $3,139.58 | $3,745.69 | $6,085.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,897.19 / $4,964.46 / $9,793.68
| Professional | | $2,897.19 | $4,964.46 | $9,793.68 |
- 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
- $2,926.58 / $5,367.62 / $9,414.14
| Professional | | $2,926.58 | $5,367.62 | $9,414.14 |