- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,206.09 / $3,206.09 / $3,206.09
| Facility | | $3,206.09 | $3,206.09 | $3,206.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.08 / $2,798.33 / $3,206.09
| Professional | | $1,459.08 | $2,798.33 | $3,206.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,298.98 / $4,085.56 / $5,381.88
| Facility | | $3,298.98 | $4,085.56 | $5,381.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,062.18 / $3,636.33 / $3,827.72
| Professional | | $3,062.18 | $3,636.33 | $3,827.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,476.09 / $11,810.42 / $32,802.44
| Facility | | $2,476.09 | $11,810.42 | $32,802.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,437.38 / $4,703.62 / $5,635.47
| Professional | | $4,437.38 | $4,703.62 | $5,635.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,011.71 / $11,331.52 / $25,828.70
| Facility | | $7,011.71 | $11,331.52 | $25,828.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,437.38 / $4,437.38 / $4,566.39
| Professional | | $4,437.38 | $4,437.38 | $4,566.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,054.17 / $3,827.72 / $16,803.40
| Facility | | $1,054.17 | $3,827.72 | $16,803.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.89 / $1,770.29 / $3,843.71
| Professional | | $1,056.89 | $1,770.29 | $3,843.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.89 / $1,773.65 / $6,723.39
| Professional | | $1,056.89 | $1,773.65 | $6,723.39 |