- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,173.21 / $2,173.21 / $2,173.21
| Facility | | $2,173.21 | $2,173.21 | $2,173.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,141.21 / $2,269.67 / $3,637.33
| Professional | | $2,141.21 | $2,269.67 | $3,637.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,661.29 / $34,194.19 / $66,228.75
| Facility | | $10,661.29 | $34,194.19 | $66,228.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,225.50 / $6,804.28 / $8,649.64
| Professional | | $4,225.50 | $6,804.28 | $8,649.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,352.36 / $7,594.22 / $18,268.91
| Facility | | $5,352.36 | $7,594.22 | $18,268.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,005.73 / $6,381.03 / $9,476.81
| Professional | | $4,005.73 | $6,381.03 | $9,476.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,865.78 / $6,942.94 / $14,384.98
| Facility | | $4,865.78 | $6,942.94 | $14,384.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,626.66 / $5,709.64 / $8,690.79
| Professional | | $3,626.66 | $5,709.64 | $8,690.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,131.19 / $3,520.99 / $6,006.39
| Facility | | $2,131.19 | $3,520.99 | $6,006.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,586.44 / $4,415.89 / $9,475.67
| Professional | | $2,586.44 | $4,415.89 | $9,475.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,720.00 / $3,500.00 / $8,152.00
| Facility | | $1,720.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,586.44 / $4,268.89 / $8,918.77
| Professional | | $2,586.44 | $4,268.89 | $8,918.77 |