- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Facility | | $6,309.57 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $7,079.46 / $15,488.17
| Professional | | $2,344.23 | $7,079.46 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $2,344.23 / $2,344.23
| Facility | | $229.09 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,344.23 / $2,344.23
| Professional | | $1,862.09 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $8,709.64 / $21,379.62
| Facility | | $5,011.87 | $8,709.64 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,388.44 / $4,786.30
| Professional | | $2,691.53 | $3,388.44 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $7,943.28 / $16,982.44
| Facility | | $5,623.41 | $7,943.28 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $4,466.84
| Professional | | $2,691.53 | $2,691.53 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,365.16 / $7,079.46
| Facility | | $2,344.23 | $4,365.16 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,412.54 / $6,165.95
| Professional | | $977.24 | $1,412.54 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,818.38
| Facility | | $2,344.23 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,949.84 / $5,011.87
| Professional | | $977.24 | $1,949.84 | $5,011.87 |