- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,258.81 / $2,258.81 / $2,258.81
| Facility | | $2,258.81 | $2,258.81 | $2,258.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,258.81 / $2,258.81 / $3,373.59
| Professional | | $2,258.81 | $2,258.81 | $3,373.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,184.29 / $10,622.61 / $19,619.08
| Facility | | $4,184.29 | $10,622.61 | $19,619.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,277.24 / $6,606.07 / $9,269.12
| Professional | | $4,277.24 | $6,606.07 | $9,269.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,564.84 / $7,891.63 / $18,984.39
| Facility | | $5,564.84 | $7,891.63 | $18,984.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,522.71 / $7,608.52 / $10,850.60
| Professional | | $4,522.71 | $7,608.52 | $10,850.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,523.81 / $7,214.84 / $14,948.34
| Facility | | $4,523.81 | $7,214.84 | $14,948.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.82 / $6,814.08 / $9,030.12
| Professional | | $3,981.82 | $6,814.08 | $9,030.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,875.27 / $3,954.00 / $5,494.48
| Facility | | $2,875.27 | $3,954.00 | $5,494.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,214.01 / $6,018.22 / $13,480.10
| Professional | | $3,214.01 | $6,018.22 | $13,480.10 |
- 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
- $3,214.01 / $5,541.00 / $10,092.70
| Professional | | $3,214.01 | $5,541.00 | $10,092.70 |