- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,073.80
| Facility | | $4,073.80 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $2,187.76
| Professional | | $1,548.82 | $1,819.70 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,187.76 / $2,187.76
| Facility | | $2,137.96 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,187.76 / $2,187.76
| Professional | | $1,778.28 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $8,511.38 / $19,952.62
| Facility | | $5,888.44 | $8,511.38 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,235.94 / $4,466.84
| Professional | | $2,570.40 | $3,235.94 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $7,762.47 / $15,848.93
| Facility | | $6,456.54 | $7,762.47 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $4,168.69
| Professional | | $2,511.89 | $2,511.89 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,890.45 / $6,606.93
| Facility | | $2,187.76 | $3,890.45 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $5,754.40
| Professional | | $933.25 | $1,318.26 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,630.27
| Facility | | $2,187.76 | $2,187.76 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,819.70 / $4,677.35
| Professional | | $933.25 | $1,819.70 | $4,677.35 |