- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,653.62 / $5,653.62 / $5,653.62
| Facility | | $5,653.62 | $5,653.62 | $5,653.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,859.41 / $5,653.62 / $5,691.19
| Professional | | $2,859.41 | $5,653.62 | $5,691.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,782.11 / $6,749.81 / $9,398.92
| Facility | | $5,782.11 | $6,749.81 | $9,398.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,399.85 / $6,412.32 / $6,749.81
| Professional | | $5,399.85 | $6,412.32 | $6,749.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,366.38 / $20,826.53 / $57,843.91
| Facility | | $4,366.38 | $20,826.53 | $57,843.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,825.13 / $8,294.62 / $9,937.91
| Professional | | $7,825.13 | $8,294.62 | $9,937.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,364.46 / $19,982.03 / $45,546.39
| Facility | | $12,364.46 | $19,982.03 | $45,546.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,825.13 / $7,825.13 / $8,052.40
| Professional | | $7,825.13 | $7,825.13 | $8,052.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,065.89 / $6,749.81 / $33,390.44
| Facility | | $2,065.89 | $6,749.81 | $33,390.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,071.23 / $3,469.31 / $6,778.04
| Professional | | $2,071.23 | $3,469.31 | $6,778.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,432.62 / $5,378.07 / $12,942.41
| Professional | | $2,432.62 | $5,378.07 | $12,942.41 |