- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,691.53 / $3,467.37
| Professional | | $1,380.38 | $2,691.53 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,630.78 / $4,570.88
| Facility | | $3,467.37 | $3,630.78 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $13,803.84 / $33,113.11
| Facility | | $9,549.93 | $13,803.84 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,011.87 / $5,370.32
| Professional | | $4,265.80 | $5,011.87 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $13,182.57 / $25,703.96
| Facility | | $10,471.29 | $13,182.57 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $5,754.40
| Professional | | $4,265.80 | $4,265.80 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $3,630.78 / $5,888.44
| Facility | | $100.00 | $3,630.78 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,235.94 / $5,888.44
| Professional | | $1,380.38 | $3,235.94 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,715.35 / $7,079.46
| Professional | | $1,445.44 | $3,715.35 | $7,079.46 |