- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,474.36 / $3,474.36 / $9,280.45
| Facility | | $3,474.36 | $3,474.36 | $9,280.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,474.36 / $4,440.91 / $5,015.62
| Professional | | $3,474.36 | $4,440.91 | $5,015.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,182.54 / $5,224.60 / $6,699.72
| Facility | | $3,182.54 | $5,224.60 | $6,699.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,912.00 / $2,026.72 / $5,224.60
| Professional | | $1,912.00 | $2,026.72 | $5,224.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,314.44 / $10,240.21 / $18,808.56
| Facility | | $7,314.44 | $10,240.21 | $18,808.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,791.98 / $11,494.12 / $16,110.47
| Facility | | $6,791.98 | $11,494.12 | $16,110.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29,407.24 / $29,407.24 / $29,407.24
| Professional | | $29,407.24 | $29,407.24 | $29,407.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,702.14 / $5,747.06 / $7,314.44
| Professional | | $4,702.14 | $5,747.06 | $7,314.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,060.54 / $7,000.96 / $9,665.51
| Professional | | $6,060.54 | $7,000.96 | $9,665.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.33 / $3,134.76 / $9,145.66
| Professional | | $2,194.33 | $3,134.76 | $9,145.66 |