- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.41 / $2,714.41 / $2,714.41
| Facility | | $2,714.41 | $2,714.41 | $2,714.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,660.56 / $2,761.59 / $4,339.53
| Professional | | $2,660.56 | $2,761.59 | $4,339.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,259.90 / $5,302.71 / $20,856.86
| Facility | | $2,259.90 | $5,302.71 | $20,856.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,775.09 / $7,756.39 / $9,859.98
| Professional | | $4,775.09 | $7,756.39 | $9,859.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,566.27 / $9,316.59 / $22,412.33
| Facility | | $6,566.27 | $9,316.59 | $22,412.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,920.99 / $7,839.01 / $11,642.14
| Professional | | $4,920.99 | $7,839.01 | $11,642.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,969.34 / $8,517.60 / $17,647.50
| Facility | | $5,969.34 | $8,517.60 | $17,647.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,455.30 / $7,008.61 / $10,676.52
| Professional | | $4,455.30 | $7,008.61 | $10,676.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.41 / $4,587.35 / $7,985.11
| Facility | | $2,714.41 | $4,587.35 | $7,985.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,997.58 / $5,366.53 / $11,012.46
| Professional | | $2,997.58 | $5,366.53 | $11,012.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,028.00 / $11,496.00 / $21,528.00
| Facility | | $5,028.00 | $11,496.00 | $21,528.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,997.58 / $5,254.38 / $10,622.49
| Professional | | $2,997.58 | $5,254.38 | $10,622.49 |