- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,162.28 / $5,754.40
| Professional | | $2,630.27 | $3,162.28 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $10,964.78 / $38,904.51
| Facility | | $5,495.41 | $10,964.78 | $38,904.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,888.44 / $9,549.93
| Professional | | $4,073.80 | $5,888.44 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $8,912.51 / $21,379.62
| Facility | | $6,309.57 | $8,912.51 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $7,762.47 / $11,481.54
| Professional | | $5,011.87 | $7,762.47 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $8,709.64 / $16,982.44
| Facility | | $6,918.31 | $8,709.64 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,456.54 / $9,772.37
| Professional | | $4,786.30 | $6,456.54 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,981.07 / $7,413.10
| Facility | | $2,951.21 | $3,981.07 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,248.07 / $10,964.78
| Professional | | $3,090.30 | $5,248.07 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,467.37 / $8,511.38
| Facility | | $1,584.89 | $3,467.37 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,370.32 / $10,471.29
| Professional | | $3,162.28 | $5,370.32 | $10,471.29 |