- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,862.09 / $2,570.40
| Professional | | $1,288.25 | $1,862.09 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,951.21 / $4,365.16
| Facility | | $2,884.03 | $2,951.21 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,951.21 / $2,951.21
| Professional | | $2,344.23 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $10,964.78 / $26,302.68
| Facility | | $6,165.95 | $10,964.78 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,890.45 / $4,365.16
| Professional | | $3,388.44 | $3,890.45 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $10,964.78 / $20,892.96
| Facility | | $8,511.38 | $10,964.78 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $4,677.35
| Professional | | $3,388.44 | $3,388.44 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,951.21 / $6,025.60
| Facility | | $1,288.25 | $2,951.21 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,479.11 / $3,801.89
| Professional | | $977.24 | $1,479.11 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.44 / $1,949.84 / $3,981.07
| Facility | | $23.44 | $1,949.84 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,479.11 / $3,467.37
| Professional | | $977.24 | $1,479.11 | $3,467.37 |