- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,408.92 / $2,408.92 / $2,408.92
| Facility | | $2,408.92 | $2,408.92 | $2,408.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,351.09 / $2,417.48 / $3,813.55
| Professional | | $2,351.09 | $2,417.48 | $3,813.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,610.82 / $13,882.05 / $23,682.56
| Facility | | $7,610.82 | $13,882.05 | $23,682.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,221.83 / $6,764.36 / $8,509.67
| Professional | | $4,221.83 | $6,764.36 | $8,509.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,802.73 / $8,233.24 / $19,806.16
| Facility | | $5,802.73 | $8,233.24 | $19,806.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,349.18 / $6,928.15 / $10,289.36
| Professional | | $4,349.18 | $6,928.15 | $10,289.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,275.21 / $7,527.16 / $15,595.41
| Facility | | $5,275.21 | $7,527.16 | $15,595.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,937.61 / $6,194.23 / $9,435.95
| Professional | | $3,937.61 | $6,194.23 | $9,435.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,445.96 / $4,078.64 / $7,195.30
| Facility | | $2,445.96 | $4,078.64 | $7,195.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,643.69 / $4,484.79 / $9,813.32
| Professional | | $2,643.69 | $4,484.79 | $9,813.32 |
- 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
- $2,489.69 / $4,276.20 / $9,620.85
| Professional | | $2,489.69 | $4,276.20 | $9,620.85 |