- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $3,981.07
| Professional | | $2,041.74 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,125.38 / $38,904.51 / $83,176.38
| Facility | | $14,125.38 | $38,904.51 | $83,176.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,495.41 / $8,709.64
| Professional | | $3,801.89 | $5,495.41 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,762.47 / $18,620.87
| Facility | | $5,495.41 | $7,762.47 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,309.57 / $9,549.93
| Professional | | $3,801.89 | $6,309.57 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $7,585.78 / $14,791.08
| Facility | | $6,025.60 | $7,585.78 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,370.32 / $8,511.38
| Professional | | $4,073.80 | $5,370.32 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,388.44 / $5,888.44
| Facility | | $2,041.74 | $3,388.44 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,168.69 / $12,022.64
| Professional | | $2,344.23 | $4,168.69 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,311.31 / $8,511.38
| Facility | | $1,445.44 | $3,311.31 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,073.80 / $8,128.31
| Professional | | $2,344.23 | $4,073.80 | $8,128.31 |