- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,923.61 / $1,923.61 / $1,923.61
| Facility | | $1,923.61 | $1,923.61 | $1,923.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,923.61 / $1,923.61 / $2,867.64
| Professional | | $1,923.61 | $1,923.61 | $2,867.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,184.29 / $10,057.10 / $18,159.54
| Facility | | $4,184.29 | $10,057.10 | $18,159.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,634.31 / $5,613.26 / $7,876.08
| Professional | | $3,634.31 | $5,613.26 | $7,876.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,743.63 / $6,727.06 / $16,182.85
| Facility | | $4,743.63 | $6,727.06 | $16,182.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.15 / $6,485.73 / $9,249.03
| Professional | | $3,855.15 | $6,485.73 | $9,249.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,856.23 / $6,150.14 / $12,742.40
| Facility | | $3,856.23 | $6,150.14 | $12,742.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,394.09 / $5,808.31 / $7,697.25
| Professional | | $3,394.09 | $5,808.31 | $7,697.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,507.23 / $3,393.25 / $4,938.64
| Facility | | $2,507.23 | $3,393.25 | $4,938.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,733.47 / $5,117.93 / $11,463.59
| Professional | | $2,733.47 | $5,117.93 | $11,463.59 |
- 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
- $2,820.48 / $5,117.93 / $8,367.17
| Professional | | $2,820.48 | $5,117.93 | $8,367.17 |