- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,981.07 / $7,585.78
| Professional | | $3,388.44 | $3,981.07 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,388.44 / $30,199.52
| Facility | | $1,479.11 | $3,388.44 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $9,120.11 / $13,489.63
| Professional | | $5,888.44 | $9,120.11 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $12,589.25 / $30,199.52
| Facility | | $7,943.28 | $12,589.25 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $9,549.93 / $14,791.08
| Professional | | $5,754.40 | $9,549.93 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $12,022.64 / $23,442.29
| Facility | | $9,772.37 | $12,022.64 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $8,709.64 / $13,803.84
| Professional | | $6,025.60 | $8,709.64 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,128.61 / $10,232.93
| Facility | | $3,311.31 | $5,128.61 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,760.83 / $26,915.35
| Professional | | $3,801.89 | $6,760.83 | $26,915.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,311.31 / $8,511.38
| Facility | | $794.33 | $3,311.31 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,606.93 / $12,589.25
| Professional | | $3,801.89 | $6,606.93 | $12,589.25 |