- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,454.71 / $3,467.37
| Professional | | $2,041.74 | $2,454.71 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,951.21 / $2,951.21
| Facility | | $2,884.03 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,951.21 / $2,951.21
| Professional | | $2,344.23 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $11,220.18 / $26,915.35
| Facility | | $7,762.47 | $11,220.18 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,265.80 / $6,025.60
| Professional | | $3,388.44 | $4,265.80 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $10,715.19 / $20,892.96
| Facility | | $8,709.64 | $10,715.19 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $5,623.41
| Professional | | $3,388.44 | $3,388.44 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,128.61 / $8,912.51
| Facility | | $2,951.21 | $5,128.61 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $7,762.47
| Professional | | $1,230.27 | $1,737.80 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $3,467.37
| Facility | | $2,951.21 | $2,951.21 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $6,165.95
| Professional | | $1,230.27 | $1,737.80 | $6,165.95 |