- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,967.36 / $1,967.36 / $1,967.36
| Facility | | $1,967.36 | $1,967.36 | $1,967.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,967.36 / $1,967.36 / $2,933.57
| Professional | | $1,967.36 | $1,967.36 | $2,933.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,184.29 / $10,060.36 / $18,165.43
| Facility | | $4,184.29 | $10,060.36 | $18,165.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,719.36 / $5,742.57 / $8,057.52
| Professional | | $3,719.36 | $5,742.57 | $8,057.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,850.60 / $6,878.75 / $16,547.77
| Facility | | $4,850.60 | $6,878.75 | $16,547.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,942.84 / $6,631.98 / $9,459.42
| Professional | | $3,942.84 | $6,631.98 | $9,459.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,943.19 / $6,288.83 / $13,029.74
| Facility | | $3,943.19 | $6,288.83 | $13,029.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,471.30 / $5,940.43 / $7,872.34
| Professional | | $3,471.30 | $5,940.43 | $7,872.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,571.48 / $3,470.56 / $5,066.47
| Facility | | $2,571.48 | $3,470.56 | $5,066.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,753.41 / $5,227.09 / $11,708.05
| Professional | | $2,753.41 | $5,227.09 | $11,708.05 |
- 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
- $2,929.50 / $5,476.54 / $8,747.03
| Professional | | $2,929.50 | $5,476.54 | $8,747.03 |