- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,157.76 / $3,157.76 / $3,157.76
| Facility | | $3,157.76 | $3,157.76 | $3,157.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,740.39 / $2,984.35 / $3,157.76
| Professional | | $1,740.39 | $2,984.35 | $3,157.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,229.52 / $3,770.02 / $5,249.64
| Facility | | $3,229.52 | $3,770.02 | $5,249.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,016.02 / $3,581.52 / $3,770.02
| Professional | | $3,016.02 | $3,581.52 | $3,770.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,677.88 / $11,632.48 / $32,308.23
| Facility | | $2,677.88 | $11,632.48 | $32,308.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,370.63 / $4,632.85 / $5,550.69
| Professional | | $4,370.63 | $4,632.85 | $5,550.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,906.06 / $11,160.79 / $25,439.55
| Facility | | $6,906.06 | $11,160.79 | $25,439.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,370.63 / $4,370.63 / $4,497.60
| Professional | | $4,370.63 | $4,370.63 | $4,497.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,124.25 / $3,770.02 / $17,719.04
| Facility | | $1,124.25 | $3,770.02 | $17,719.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.15 / $1,887.97 / $3,785.78
| Professional | | $1,127.15 | $1,887.97 | $3,785.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.82 / $2,681.48 / $7,043.17
| Professional | | $1,323.82 | $2,681.48 | $7,043.17 |