- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,736.70 / $2,139.32 / $2,139.32
| Facility | | $1,736.70 | $2,139.32 | $2,139.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.70 / $2,155.63 / $3,395.04
| Professional | | $1,736.70 | $2,155.63 | $3,395.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,610.82 / $12,653.73 / $23,682.56
| Facility | | $7,610.82 | $12,653.73 | $23,682.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,203.97 / $5,206.13 / $7,445.67
| Professional | | $3,203.97 | $5,206.13 | $7,445.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,206.72 / $7,387.58 / $17,771.82
| Facility | | $5,206.72 | $7,387.58 | $17,771.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,497.47 / $5,802.62 / $9,098.58
| Professional | | $3,497.47 | $5,802.62 | $9,098.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,733.38 / $6,754.02 / $13,993.56
| Facility | | $4,733.38 | $6,754.02 | $13,993.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,285.69 / $5,225.53 / $8,296.53
| Professional | | $3,285.69 | $5,225.53 | $8,296.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,139.32 / $3,548.32 / $5,866.83
| Facility | | $2,139.32 | $3,548.32 | $5,866.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,541.90 / $4,712.55 / $13,048.80
| Professional | | $2,541.90 | $4,712.55 | $13,048.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,940.00 / $7,872.00 / $11,531.00
| Facility | | $3,940.00 | $7,872.00 | $11,531.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,472.58 / $4,531.52 / $8,661.76
| Professional | | $2,472.58 | $4,531.52 | $8,661.76 |