- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,570.40 / $3,981.07
| Professional | | $2,137.96 | $2,570.40 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,709.64 / $32,359.37
| Facility | | $4,466.84 | $8,709.64 | $32,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,677.35 / $7,585.78
| Professional | | $3,162.28 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $7,244.36 / $17,378.01
| Facility | | $5,128.61 | $7,244.36 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,025.60 / $9,120.11
| Professional | | $3,981.07 | $6,025.60 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,918.31 / $13,489.63
| Facility | | $5,623.41 | $6,918.31 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,011.87 / $7,585.78
| Professional | | $3,801.89 | $5,011.87 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,467.37 / $5,888.44
| Facility | | $2,398.83 | $3,467.37 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,365.16 / $9,120.11
| Professional | | $2,570.40 | $4,365.16 | $9,120.11 |
- 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
- $2,754.23 / $4,365.16 / $8,709.64
| Professional | | $2,754.23 | $4,365.16 | $8,709.64 |