- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,110.40 / $3,110.40 / $5,243.57
| Facility | | $3,110.40 | $3,110.40 | $5,243.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,488.32 / $2,839.79 / $4,602.39
| Professional | | $2,488.32 | $2,839.79 | $4,602.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $2,220.92 / $4,757.81
| Facility | | $1.00 | $2,220.92 | $4,757.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,115.07 / $2,564.52 / $2,643.84
| Professional | | $2,115.07 | $2,564.52 | $2,643.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,097.15 / $8,646.52 / $20,800.36
| Facility | | $6,097.15 | $8,646.52 | $20,800.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,714.63 / $3,185.16 / $3,447.57
| Professional | | $2,714.63 | $3,185.16 | $3,447.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,800.89 / $7,904.99 / $16,378.24
| Facility | | $4,800.89 | $7,904.99 | $16,378.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,714.63 / $2,714.63 / $3,393.28
| Professional | | $2,714.63 | $2,714.63 | $3,393.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.02 / $2,961.60 / $5,005.10
| Facility | | $1,388.02 | $2,961.60 | $5,005.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,592.00 / $2,592.00 / $5,113.34
| Professional | | $2,592.00 | $2,592.00 | $5,113.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,592.00 / $2,592.00 / $4,698.78
| Professional | | $2,592.00 | $2,592.00 | $4,698.78 |