- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,265.58 / $2,265.58 / $2,265.58
| Facility | | $2,265.58 | $2,265.58 | $2,265.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,265.58 / $2,648.26 / $3,307.73
| Professional | | $2,265.58 | $2,648.26 | $3,307.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,112.41 / $9,643.20 / $18,901.23
| Facility | | $4,112.41 | $9,643.20 | $18,901.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,487.10 / $5,344.11 / $8,042.91
| Professional | | $3,487.10 | $5,344.11 | $8,042.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,023.26 / $7,123.61 / $17,136.81
| Facility | | $5,023.26 | $7,123.61 | $17,136.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,081.52 / $6,642.68 / $9,633.53
| Professional | | $4,081.52 | $6,642.68 | $9,633.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,083.55 / $6,512.69 / $13,493.55
| Facility | | $4,083.55 | $6,512.69 | $13,493.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,410.87 / $5,474.45 / $8,149.23
| Professional | | $3,410.87 | $5,474.45 | $8,149.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $3,590.62 / $5,590.06
| Facility | | $1,751.00 | $3,590.62 | $5,590.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.67 / $4,693.22 / $9,283.92
| Professional | | $2,511.67 | $4,693.22 | $9,283.92 |
- 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
- $2,211.03 / $4,563.35 / $8,819.83
| Professional | | $2,211.03 | $4,563.35 | $8,819.83 |