- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,168.69 / $30,902.95
| Professional | | $2,290.87 | $4,168.69 | $30,902.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $5,128.61
| Professional | | $3,630.78 | $3,630.78 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $5,623.41 / $7,079.46
| Professional | | $60.26 | $5,623.41 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $6,760.83 / $11,748.98
| Facility | | $5,754.40 | $6,760.83 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,495.41 / $8,128.31
| Professional | | $4,265.80 | $5,495.41 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $7,585.78 / $7,762.47
| Professional | | $6,918.31 | $7,585.78 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $7,762.47 / $9,332.54
| Professional | | $5,623.41 | $7,762.47 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,630.78 / $5,370.32
| Facility | | $2,951.21 | $3,630.78 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,548.13 / $5,370.32
| Professional | | $2,754.23 | $3,548.13 | $5,370.32 |