- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,201.62 / $4,283.05 / $5,991.01
| Facility | | $2,201.62 | $4,283.05 | $5,991.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.07 / $1,695.25 / $1,695.25
| Professional | | $1,453.07 | $1,695.25 | $1,695.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,641.94 / $2,641.94 / $2,641.94
| Facility | | $2,641.94 | $2,641.94 | $2,641.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,641.94 / $3,998.40 / $4,998.00
| Professional | | $2,641.94 | $3,998.40 | $4,998.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,421.78 / $2,752.03 / $3,984.93
| Professional | | $2,421.78 | $2,752.03 | $3,984.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,201.62 / $2,862.11 / $10,457.70
| Facility | | $2,201.62 | $2,862.11 | $10,457.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.97 / $1,320.97 / $5,567.90
| Professional | | $1,320.97 | $1,320.97 | $5,567.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,641.94 / $2,862.11 / $6,055.42
| Facility | | $2,641.94 | $2,862.11 | $6,055.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,641.94 / $4,535.34 / $6,055.42
| Professional | | $2,641.94 | $4,535.34 | $6,055.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.97 / $1,320.97 / $7,104.85
| Professional | | $1,320.97 | $1,320.97 | $7,104.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,739.28 / $2,201.62 / $2,201.62
| Professional | | $1,739.28 | $2,201.62 | $2,201.62 |