- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,398.83 / $3,311.31
| Professional | | $1,318.26 | $2,398.83 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $7,943.28 / $22,387.21
| Facility | | $4,168.69 | $7,943.28 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,019.95 / $4,365.16
| Professional | | $2,884.03 | $3,019.95 | $4,365.16 |
- 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
- $3,630.78 / $6,025.60 / $9,332.54
| Professional | | $3,630.78 | $6,025.60 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $7,585.78 / $14,454.40
| Facility | | $6,025.60 | $7,585.78 | $14,454.40 |
- 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
- $1,995.26 / $3,162.28 / $5,888.44
| Facility | | $1,995.26 | $3,162.28 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,801.89 / $16,982.44
| Professional | | $2,089.30 | $3,801.89 | $16,982.44 |
- 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
- $1,778.28 / $3,090.30 / $7,244.36
| Professional | | $1,778.28 | $3,090.30 | $7,244.36 |