- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,073.80
| Facility | | $4,073.80 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,467.37 / $4,466.84
| Professional | | $2,344.23 | $3,467.37 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,128.31 / $10,964.78
| Facility | | $5,128.61 | $8,128.31 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,168.69 / $4,570.88
| Professional | | $4,073.80 | $4,168.69 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,073.80 / $4,073.80
| Facility | | $2,454.71 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $5,011.87
| Professional | | $2,951.21 | $2,951.21 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,691.53 / $3,715.35
| Professional | | $2,454.71 | $2,691.53 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,570.88 / $7,943.28
| Facility | | $2,290.87 | $4,570.88 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,981.07 / $4,365.16
| Facility | | $2,238.72 | $3,981.07 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,754.23 / $4,073.80
| Professional | | $2,238.72 | $2,754.23 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33,884.42 / $33,884.42 / $33,884.42
| Facility | | $33,884.42 | $33,884.42 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41,686.94 / $41,686.94 / $44,668.36
| Professional | | $41,686.94 | $41,686.94 | $44,668.36 |