- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,162.28 / $4,073.80
| Professional | | $2,041.74 | $3,162.28 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,677.35 / $9,332.54
| Facility | | $3,890.45 | $4,677.35 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,630.78 / $3,981.07
| Professional | | $3,548.13 | $3,630.78 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,801.89 / $3,801.89
| Facility | | $2,089.30 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $4,365.16
| Professional | | $2,754.23 | $2,754.23 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,344.23 / $3,162.28
| Professional | | $2,187.76 | $2,344.23 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,981.07 / $6,918.31
| Facility | | $2,041.74 | $3,981.07 | $6,918.31 |
- 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
- $1,949.84 / $3,548.13 / $3,801.89
| Facility | | $1,949.84 | $3,548.13 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,344.23 / $3,630.78
| Professional | | $1,949.84 | $2,344.23 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29,512.09 / $29,512.09 / $29,512.09
| Facility | | $29,512.09 | $29,512.09 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30,902.95 / $30,902.95 / $46,773.51
| Professional | | $30,902.95 | $30,902.95 | $46,773.51 |