- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,884.03 / $4,786.30
| Professional | | $2,344.23 | $2,884.03 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,370.32 / $29,512.09
| Facility | | $5,248.07 | $5,370.32 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,168.69 / $5,623.41
| Professional | | $2,570.40 | $4,168.69 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $7,079.46 / $9,332.54
| Facility | | $5,623.41 | $7,079.46 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,897.79 / $4,897.79
| Professional | | $4,265.80 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,715.35
| Professional | | $2,691.53 | $2,691.53 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $4,897.79 / $9,772.37
| Facility | | $83.18 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $7,244.36
| Professional | | $4,786.30 | $4,786.30 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,265.80
| Professional | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,370.32 / $29,512.09
| Facility | | $5,248.07 | $5,370.32 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,168.69 / $5,623.41
| Professional | | $2,570.40 | $4,168.69 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.07 / $3,890.45 / $6,918.31
| Facility | | $4.07 | $3,890.45 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,890.45 / $4,786.30
| Professional | | $2,238.72 | $3,890.45 | $4,786.30 |