- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,420.17 / $2,420.17 / $8,177.00
| Facility | | $2,420.17 | $2,420.17 | $8,177.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,802.26 / $2,420.17 / $2,420.17
| Professional | | $1,802.26 | $2,420.17 | $2,420.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,445.92 / $2,574.65 / $2,574.65
| Facility | | $2,445.92 | $2,574.65 | $2,574.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.71 / $2,574.65 / $2,574.65
| Professional | | $2,059.71 | $2,574.65 | $2,574.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,017.55 / $9,391.84 / $22,593.35
| Facility | | $6,017.55 | $9,391.84 | $22,593.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,987.90 / $3,757.07 / $5,212.59
| Professional | | $2,987.90 | $3,757.07 | $5,212.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,214.74 / $8,586.40 / $17,790.04
| Facility | | $5,214.74 | $8,586.40 | $17,790.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.32 / $2,958.32 / $4,676.01
| Professional | | $2,958.32 | $2,958.32 | $4,676.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,574.65 / $4,634.37 / $7,801.19
| Facility | | $2,574.65 | $4,634.37 | $7,801.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,313.07 / $2,059.71 / $6,788.84
| Professional | | $1,313.07 | $2,059.71 | $6,788.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,313.07 / $1,544.79 / $5,462.89
| Professional | | $1,313.07 | $1,544.79 | $5,462.89 |