- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Facility | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,019.95 / $5,754.40
| Professional | | $2,511.89 | $3,019.95 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $16,982.44 / $41,686.94
| Facility | | $7,762.47 | $16,982.44 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,918.31 / $10,232.93
| Professional | | $4,466.84 | $6,918.31 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $9,772.37 / $22,908.68
| Facility | | $6,025.60 | $9,772.37 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,413.10 / $11,481.54
| Professional | | $4,365.16 | $7,413.10 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $9,332.54 / $18,197.01
| Facility | | $7,413.10 | $9,332.54 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,606.93 / $10,471.29
| Professional | | $4,677.35 | $6,606.93 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,630.78 / $7,762.47
| Facility | | $2,238.72 | $3,630.78 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,128.61 / $20,417.38
| Professional | | $2,884.03 | $5,128.61 | $20,417.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,311.31 / $8,511.38
| Facility | | $794.33 | $3,311.31 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,897.79 / $9,549.93
| Professional | | $2,818.38 | $4,897.79 | $9,549.93 |