- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,443.80 / $1,443.80 / $6,575.00
| Facility | | $1,443.80 | $1,443.80 | $6,575.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.91 / $1,443.80 / $2,281.44
| Professional | | $1,386.91 | $1,443.80 | $2,281.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,365.24 / $11,518.20 / $22,604.47
| Facility | | $6,365.24 | $11,518.20 | $22,604.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,459.42 / $3,944.21 / $4,976.29
| Professional | | $2,459.42 | $3,944.21 | $4,976.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,478.44 / $4,935.41 / $11,872.79
| Facility | | $3,478.44 | $4,935.41 | $11,872.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.13 / $4,154.70 / $6,170.36
| Professional | | $2,608.13 | $4,154.70 | $6,170.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.22 / $4,512.14 / $9,348.65
| Facility | | $3,162.22 | $4,512.14 | $9,348.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,361.32 / $3,714.58 / $5,658.58
| Professional | | $2,361.32 | $3,714.58 | $5,658.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,475.71 / $2,494.61 / $5,331.00
| Facility | | $1,475.71 | $2,494.61 | $5,331.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.49 / $2,898.94 / $5,825.71
| Professional | | $1,601.49 | $2,898.94 | $5,825.71 |
- 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
- $1,532.99 / $2,918.63 / $5,441.75
| Professional | | $1,532.99 | $2,918.63 | $5,441.75 |