- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,754.40 / $8,511.38
| Professional | | $4,168.69 | $5,754.40 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $7,244.36 / $7,413.10
| Facility | | $5,888.44 | $7,244.36 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,897.79 / $6,918.31
| Professional | | $2,454.71 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $7,585.78 / $7,585.78
| Professional | | $5,370.32 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $7,413.10
| Facility | | $3,715.35 | $3,715.35 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $3,715.35 / $12,882.50
| Professional | | $812.83 | $3,715.35 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $9,772.37 / $9,772.37
| Professional | | $2,951.21 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Professional | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $7,244.36 / $7,413.10
| Facility | | $5,888.44 | $7,244.36 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,897.79 / $7,244.36
| Professional | | $2,454.71 | $4,897.79 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.01 / $616.60 / $4,677.35
| Facility | | $5.01 | $616.60 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,981.07 / $9,772.37
| Professional | | $2,398.83 | $3,981.07 | $9,772.37 |