- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,211.02 / $3,211.02 / $3,211.02
| Facility | | $3,211.02 | $3,211.02 | $3,211.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,211.02 / $3,211.02 / $3,786.13
| Professional | | $3,211.02 | $3,211.02 | $3,786.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,425.46 / $4,868.01 / $4,917.18
| Professional | | $4,425.46 | $4,868.01 | $4,917.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,813.78 / $5,538.71 / $5,538.71
| Facility | | $3,813.78 | $5,538.71 | $5,538.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,813.78 / $5,538.71 / $8,540.81
| Professional | | $3,813.78 | $5,538.71 | $8,540.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,684.65 / $5,458.73 / $23,822.60
| Facility | | $2,684.65 | $5,458.73 | $23,822.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,917.03 / $2,974.48 / $4,186.67
| Professional | | $1,917.03 | $2,974.48 | $4,186.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,522.51 / $5,538.71 / $6,978.59
| Facility | | $5,522.51 | $5,538.71 | $6,978.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,605.34 / $6,545.75 / $11,410.66
| Professional | | $4,605.34 | $6,545.75 | $11,410.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,917.03 / $2,659.79 / $3,437.68
| Professional | | $1,917.03 | $2,659.79 | $3,437.68 |