- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,268.32 / $4,268.32 / $4,268.32
| Facility | | $4,268.32 | $4,268.32 | $4,268.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,924.20 / $3,668.13 / $4,268.32
| Professional | | $1,924.20 | $3,668.13 | $4,268.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.32 / $5,095.91 / $7,095.89
| Facility | | $4,365.32 | $5,095.91 | $7,095.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,076.73 / $4,841.10 / $5,095.91
| Professional | | $4,076.73 | $4,841.10 | $5,095.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,001.57 / $15,723.09 / $43,669.55
| Facility | | $3,001.57 | $15,723.09 | $43,669.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,907.75 / $6,262.22 / $7,502.84
| Professional | | $5,907.75 | $6,262.22 | $7,502.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,334.61 / $15,085.53 / $34,385.48
| Facility | | $9,334.61 | $15,085.53 | $34,385.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,907.75 / $5,907.75 / $6,079.20
| Professional | | $5,907.75 | $5,907.75 | $6,079.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,986.64 / $5,095.91 / $21,089.02
| Facility | | $2,986.64 | $5,095.91 | $21,089.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.73 / $2,205.53 / $5,117.21
| Professional | | $1,316.73 | $2,205.53 | $5,117.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.73 / $2,183.82 / $5,095.91
| Professional | | $1,316.73 | $2,183.82 | $5,095.91 |