- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,712.61 / $1,712.61 / $1,712.61
| Facility | | $1,712.61 | $1,712.61 | $1,712.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,674.18 / $1,712.61 / $2,547.33
| Professional | | $1,674.18 | $1,712.61 | $2,547.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,184.29 / $9,471.49 / $16,270.01
| Facility | | $4,184.29 | $9,471.49 | $16,270.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,227.51 / $4,984.93 / $6,994.47
| Professional | | $3,227.51 | $4,984.93 | $6,994.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,228.17 / $5,996.06 / $14,424.34
| Facility | | $4,228.17 | $5,996.06 | $14,424.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,437.75 / $5,780.96 / $8,247.62
| Professional | | $3,437.75 | $5,780.96 | $8,247.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,437.19 / $5,481.84 / $11,357.75
| Facility | | $3,437.19 | $5,481.84 | $11,357.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,026.61 / $5,179.43 / $6,863.87
| Professional | | $3,026.61 | $5,179.43 | $6,863.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,159.36 / $3,052.10 / $3,954.00
| Facility | | $2,159.36 | $3,052.10 | $3,954.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,432.16 / $4,531.30 / $10,149.59
| Professional | | $2,432.16 | $4,531.30 | $10,149.59 |
- 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
- $2,432.16 / $4,171.99 / $7,555.95
| Professional | | $2,432.16 | $4,171.99 | $7,555.95 |