- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $7,943.28 / $14,454.40
| Facility | | $5,754.40 | $7,943.28 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,235.94 / $6,025.60
| Professional | | $2,754.23 | $3,235.94 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $20,892.96 / $40,738.03
| Facility | | $15,848.93 | $20,892.96 | $40,738.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,570.88 / $6,025.60
| Professional | | $2,691.53 | $4,570.88 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $5,495.41 / $9,772.37
| Professional | | $1,445.44 | $5,495.41 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,466.84 / $7,762.47
| Facility | | $2,754.23 | $4,466.84 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,165.95 / $22,387.21
| Professional | | $3,981.07 | $6,165.95 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $7,079.46 / $9,772.37
| Professional | | $5,754.40 | $7,079.46 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $6,606.93 / $9,772.37
| Professional | | $5,248.07 | $6,606.93 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.14 / $15.14 / $7,943.28
| Professional | | $15.14 | $15.14 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,570.88 / $13,803.84
| Facility | | $3,235.94 | $4,570.88 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,248.07 / $8,128.31
| Professional | | $3,467.37 | $5,248.07 | $8,128.31 |