- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,679.48 / $2,679.48 / $2,679.48
| Facility | | $2,679.48 | $2,679.48 | $2,679.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,780.26 / $2,679.48 / $2,836.44
| Professional | | $1,780.26 | $2,679.48 | $2,836.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,323.64 / $4,116.10 / $5,422.13
| Facility | | $3,323.64 | $4,116.10 | $5,422.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,085.06 / $3,663.51 / $3,856.33
| Professional | | $3,085.06 | $3,663.51 | $3,856.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.75 / $11,898.36 / $33,046.69
| Facility | | $2,326.75 | $11,898.36 | $33,046.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,470.75 / $4,739.00 / $5,677.85
| Professional | | $4,470.75 | $4,739.00 | $5,677.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,063.91 / $11,415.89 / $26,021.01
| Facility | | $7,063.91 | $11,415.89 | $26,021.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,470.75 / $4,470.75 / $4,600.39
| Professional | | $4,470.75 | $4,470.75 | $4,600.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,142.82 / $3,856.33 / $17,957.82
| Facility | | $1,142.82 | $3,856.33 | $17,957.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.77 / $1,908.05 / $4,221.10
| Professional | | $1,145.77 | $1,908.05 | $4,221.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.77 / $1,746.34 / $4,011.92
| Professional | | $1,145.77 | $1,746.34 | $4,011.92 |