- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,973.62 / $1,973.62 / $1,973.62
| Facility | | $1,973.62 | $1,973.62 | $1,973.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,973.62 / $1,973.62 / $2,942.20
| Professional | | $1,973.62 | $1,973.62 | $2,942.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,142.55 / $10,272.64 / $18,739.34
| Facility | | $4,142.55 | $10,272.64 | $18,739.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,734.47 / $5,765.13 / $8,089.18
| Professional | | $3,734.47 | $5,765.13 | $8,089.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,870.81 / $6,907.42 / $16,616.73
| Facility | | $4,870.81 | $6,907.42 | $16,616.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,960.51 / $6,659.62 / $9,501.82
| Professional | | $3,960.51 | $6,659.62 | $9,501.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,959.62 / $6,315.04 / $13,084.04
| Facility | | $3,959.62 | $6,315.04 | $13,084.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,486.86 / $5,967.06 / $7,907.63
| Professional | | $3,486.86 | $5,967.06 | $7,907.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,580.65 / $3,486.66 / $5,073.89
| Facility | | $2,580.65 | $3,486.66 | $5,073.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,817.60 / $5,250.26 / $11,759.96
| Professional | | $2,817.60 | $5,250.26 | $11,759.96 |
- 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
- $2,929.92 / $5,250.26 / $8,527.83
| Professional | | $2,929.92 | $5,250.26 | $8,527.83 |