- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,130.09 / $6,130.09 / $6,130.09
| Facility | | $6,130.09 | $6,130.09 | $6,130.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,904.07 / $5,087.97 / $6,130.09
| Professional | | $4,904.07 | $5,087.97 | $6,130.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $7,082.36 / $30,864.82
| Facility | | $1.00 | $7,082.36 | $30,864.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,315.79 / $5,394.74 / $5,394.74
| Professional | | $4,315.79 | $5,394.74 | $5,394.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,709.71 / $8,097.07 / $19,478.61
| Facility | | $5,709.71 | $8,097.07 | $19,478.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,567.55 / $3,228.50 / $3,443.73
| Professional | | $2,567.55 | $3,228.50 | $3,443.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,495.83 / $7,402.67 / $15,337.49
| Facility | | $4,495.83 | $7,402.67 | $15,337.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,542.13 / $2,542.13 / $3,177.66
| Professional | | $2,542.13 | $2,542.13 | $3,177.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,074.81 / $6,130.09 / $10,359.85
| Facility | | $2,074.81 | $6,130.09 | $10,359.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,108.41 / $5,108.41 / $10,077.56
| Professional | | $5,108.41 | $5,108.41 | $10,077.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,108.41 / $5,108.41 / $9,260.53
| Professional | | $5,108.41 | $5,108.41 | $9,260.53 |