- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.61 / $1,304.61 / $1,304.61
| Facility | | $1,304.61 | $1,304.61 | $1,304.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.61 / $1,390.91 / $2,016.26
| Professional | | $1,304.61 | $1,390.91 | $2,016.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,511.39 / $7,809.75 / $14,098.13
| Facility | | $4,511.39 | $7,809.75 | $14,098.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,316.00 / $3,571.21 / $5,010.84
| Professional | | $2,316.00 | $3,571.21 | $5,010.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,310.10 / $4,694.13 / $11,292.36
| Facility | | $3,310.10 | $4,694.13 | $11,292.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,690.65 / $4,525.72 / $6,455.24
| Professional | | $2,690.65 | $4,525.72 | $6,455.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,690.87 / $4,291.56 / $8,891.62
| Facility | | $2,690.87 | $4,291.56 | $8,891.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,368.86 / $4,053.83 / $5,372.19
| Professional | | $2,368.86 | $4,053.83 | $5,372.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,804.25 / $2,368.42 / $3,675.03
| Facility | | $1,804.25 | $2,368.42 | $3,675.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,794.41 / $3,599.54 / $7,226.42
| Professional | | $1,794.41 | $3,599.54 | $7,226.42 |
- 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
- $1,821.81 / $3,424.58 / $5,550.03
| Professional | | $1,821.81 | $3,424.58 | $5,550.03 |