- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $10,964.78 / $10,964.78
| Facility | | $2,344.23 | $10,964.78 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,905.46 / $2,951.21
| Professional | | $1,584.89 | $1,905.46 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $7,079.46
| Facility | | $3,981.07 | $3,981.07 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,248.07 / $6,456.54
| Professional | | $2,454.71 | $5,248.07 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,691.53 / $3,388.44
| Professional | | $2,344.23 | $2,691.53 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,388.44
| Facility | | $2,454.71 | $2,454.71 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,311.31 / $6,456.54
| Facility | | $1,819.70 | $3,311.31 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,691.53 / $3,388.44
| Professional | | $79.43 | $2,691.53 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,265.80 / $9,549.93
| Facility | | $3,630.78 | $4,265.80 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,089.30 / $2,951.21
| Professional | | $1,949.84 | $2,089.30 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $2,951.21
| Professional | | $1,023.29 | $1,023.29 | $2,951.21 |