- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,570.88 / $4,570.88
| Facility | | $4,365.16 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,801.89 / $5,128.61
| Professional | | $1,995.26 | $3,801.89 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $5,495.41
| Facility | | $3,548.13 | $3,548.13 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $7,943.28
| Professional | | $6,309.57 | $6,309.57 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,888.44 / $16,218.10
| Facility | | $3,630.78 | $5,888.44 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,467.37 / $30,199.52
| Professional | | $2,290.87 | $3,467.37 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,370.32 / $5,370.32
| Professional | | $4,466.84 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $10,964.78
| Professional | | $4,466.84 | $4,466.84 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,025.60 / $7,943.28
| Professional | | $5,011.87 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,467.37 / $5,623.41
| Professional | | $2,187.76 | $3,467.37 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |