- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,371.92 / $2,371.92 / $2,371.92
| Facility | | $2,371.92 | $2,371.92 | $2,371.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,371.92 / $2,785.48 / $3,492.66
| Professional | | $2,371.92 | $2,785.48 | $3,492.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.89 / $9,689.87 / $19,011.82
| Facility | | $4,570.89 | $9,689.87 | $19,011.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,663.71 / $5,590.15 / $8,469.10
| Professional | | $3,663.71 | $5,590.15 | $8,469.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.99 / $7,443.72 / $17,906.87
| Facility | | $5,248.99 | $7,443.72 | $17,906.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,252.83 / $6,921.48 / $10,037.86
| Professional | | $4,252.83 | $6,921.48 | $10,037.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,267.05 / $6,805.34 / $14,099.90
| Facility | | $4,267.05 | $6,805.34 | $14,099.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,554.03 / $5,704.22 / $8,491.27
| Professional | | $3,554.03 | $5,704.22 | $8,491.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,220.45 / $3,756.17 / $5,989.18
| Facility | | $3,220.45 | $3,756.17 | $5,989.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,032.85 / $5,000.21 / $9,855.73
| Professional | | $3,032.85 | $5,000.21 | $9,855.73 |
- 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
- $3,079.15 / $5,151.81 / $9,363.04
| Professional | | $3,079.15 | $5,151.81 | $9,363.04 |