- 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
- $2,398.83 / $3,162.28 / $4,677.35
| Professional | | $2,398.83 | $3,162.28 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $11,220.18 / $39,810.72
| Facility | | $5,495.41 | $11,220.18 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $6,025.60 / $9,549.93
| Professional | | $4,168.69 | $6,025.60 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $9,120.11 / $21,877.62
| Facility | | $6,456.54 | $9,120.11 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $7,762.47 / $11,748.98
| Professional | | $5,128.61 | $7,762.47 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $8,709.64 / $16,982.44
| Facility | | $7,079.46 | $8,709.64 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,606.93 / $9,772.37
| Professional | | $4,897.79 | $6,606.93 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,981.07 / $7,585.78
| Facility | | $2,570.40 | $3,981.07 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,248.07 / $10,964.78
| Professional | | $2,884.03 | $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
- $2,884.03 / $5,370.32 / $10,715.19
| Professional | | $2,884.03 | $5,370.32 | $10,715.19 |