- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,471.73 / $1,471.73 / $1,471.73
| Facility | | $1,471.73 | $1,471.73 | $1,471.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.73 / $1,471.73 / $2,192.46
| Professional | | $1,471.73 | $1,471.73 | $2,192.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,174.60 / $12,732.95 / $25,478.69
| Facility | | $7,174.60 | $12,732.95 | $25,478.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,779.87 / $4,291.52 / $6,021.53
| Professional | | $2,779.87 | $4,291.52 | $6,021.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,631.00 / $5,149.21 / $12,387.12
| Facility | | $3,631.00 | $5,149.21 | $12,387.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.69 / $4,964.47 / $7,081.52
| Professional | | $2,951.69 | $4,964.47 | $7,081.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.74 / $4,707.60 / $9,753.64
| Facility | | $2,951.74 | $4,707.60 | $9,753.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,598.69 / $4,447.13 / $5,893.40
| Professional | | $2,598.69 | $4,447.13 | $5,893.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,922.01 / $3,020.04 / $10,533.00
| Facility | | $1,922.01 | $3,020.04 | $10,533.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.13 / $3,906.92 / $8,751.04
| Professional | | $2,100.13 | $3,906.92 | $8,751.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,940.00 / $8,689.00 / $11,531.00
| Facility | | $3,940.00 | $8,689.00 | $11,531.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,975.28 / $3,923.86 / $6,525.10
| Professional | | $1,975.28 | $3,923.86 | $6,525.10 |