- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $3,739.65
| Facility | | $3,739.65 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,651.66 / $3,739.65 / $3,739.65
| Professional | | $3,651.66 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $683.80 / $1,442.82 / $2,324.92
| Facility | | $683.80 | $1,442.82 | $2,324.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,519.67 / $3,519.67 / $4,311.59
| Professional | | $3,519.67 | $3,519.67 | $4,311.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.21 / $357.21 / $357.21
| Professional | | $357.21 | $357.21 | $357.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $3,739.65
| Facility | | $3,739.65 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $3,739.65
| Professional | | $3,739.65 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,342.11 / $3,931.89 / $4,179.60
| Professional | | $3,342.11 | $3,931.89 | $4,179.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $424.18 / $4,399.59 / $6,170.42
| Facility | | $424.18 | $4,399.59 | $6,170.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.48 / $704.00 / $3,785.16
| Professional | | $620.48 | $704.00 | $3,785.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,483.01 / $4,179.60 / $5,389.51
| Facility | | $3,483.01 | $4,179.60 | $5,389.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,483.01 / $4,179.60 / $5,389.51
| Professional | | $3,483.01 | $4,179.60 | $5,389.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,666.33 / $3,666.33 / $4,399.59
| Professional | | $3,666.33 | $3,666.33 | $4,399.59 |