- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,210.88 / $3,210.88 / $3,210.88
| Facility | | $3,210.88 | $3,210.88 | $3,210.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.64 / $2,778.32 / $3,210.88
| Professional | | $1,426.64 | $2,778.32 | $3,210.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,283.86 / $3,833.45 / $5,337.98
| Facility | | $3,283.86 | $3,833.45 | $5,337.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,066.76 / $3,641.78 / $3,833.45
| Professional | | $3,066.76 | $3,641.78 | $3,833.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,479.82 / $11,828.01 / $32,851.30
| Facility | | $2,479.82 | $11,828.01 | $32,851.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,444.13 / $4,710.77 / $5,644.04
| Professional | | $4,444.13 | $4,710.77 | $5,644.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,022.15 / $11,348.40 / $25,867.16
| Facility | | $7,022.15 | $11,348.40 | $25,867.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,444.13 / $4,444.13 / $4,573.20
| Professional | | $4,444.13 | $4,444.13 | $4,573.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,030.73 / $3,833.45 / $16,444.91
| Facility | | $1,030.73 | $3,833.45 | $16,444.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.39 / $1,730.93 / $3,849.48
| Professional | | $1,033.39 | $1,730.93 | $3,849.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.70 / $2,848.29 / $6,652.46
| Professional | | $1,213.70 | $2,848.29 | $6,652.46 |