- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,206.71 / $2,206.71 / $2,206.71
| Facility | | $2,206.71 | $2,206.71 | $2,206.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,206.71 / $2,411.01 / $3,144.28
| Professional | | $2,206.71 | $2,411.01 | $3,144.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,977.29 / $9,158.60 / $20,312.33
| Facility | | $1,977.29 | $9,158.60 | $20,312.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.22 / $606.53 / $606.53
| Professional | | $485.22 | $606.53 | $606.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,854.71 / $12,557.10 / $30,207.79
| Facility | | $8,854.71 | $12,557.10 | $30,207.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,234.43 / $11,774.04 / $17,075.28
| Professional | | $7,234.43 | $11,774.04 | $17,075.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,198.25 / $11,480.20 / $23,785.66
| Facility | | $7,198.25 | $11,480.20 | $23,785.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,045.72 / $9,703.37 / $14,444.39
| Professional | | $6,045.72 | $9,703.37 | $14,444.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,709.81 / $4,991.51 / $8,795.00
| Facility | | $2,709.81 | $4,991.51 | $8,795.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,802.08 / $5,109.67 / $13,980.43
| Professional | | $2,802.08 | $5,109.67 | $13,980.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $3,500.00 / $8,152.00
| Facility | | $1,751.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,465.76 / $5,604.15 / $13,349.05
| Professional | | $2,465.76 | $5,604.15 | $13,349.05 |