- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,454.71 / $4,466.84
| Professional | | $2,041.74 | $2,454.71 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $14,454.40 / $41,686.94
| Facility | | $7,762.47 | $14,454.40 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,754.40 / $8,317.64
| Professional | | $3,630.78 | $5,754.40 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $7,762.47 / $18,620.87
| Facility | | $4,897.79 | $7,762.47 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $6,025.60 / $9,332.54
| Professional | | $3,548.13 | $6,025.60 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $7,413.10 / $14,791.08
| Facility | | $6,025.60 | $7,413.10 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,370.32 / $8,511.38
| Professional | | $3,715.35 | $5,370.32 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,019.95 / $6,309.57
| Facility | | $2,041.74 | $3,019.95 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,265.80 / $16,595.87
| Professional | | $2,290.87 | $4,265.80 | $16,595.87 |
- 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
- $2,238.72 / $3,981.07 / $7,762.47
| Professional | | $2,238.72 | $3,981.07 | $7,762.47 |