- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,105.93 / $5,105.93 / $5,105.93
| Facility | | $5,105.93 | $5,105.93 | $5,105.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,412.09 / $4,626.08 / $5,105.93
| Professional | | $2,412.09 | $4,626.08 | $5,105.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,221.97 / $6,095.93 / $8,488.41
| Facility | | $5,221.97 | $6,095.93 | $8,488.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,876.74 / $5,791.13 / $6,095.93
| Professional | | $4,876.74 | $5,791.13 | $6,095.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,943.38 / $18,809.15 / $52,240.83
| Facility | | $3,943.38 | $18,809.15 | $52,240.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,066.88 / $7,490.89 / $8,974.93
| Professional | | $7,066.88 | $7,490.89 | $8,974.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,166.77 / $18,046.46 / $41,134.51
| Facility | | $11,166.77 | $18,046.46 | $41,134.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,066.88 / $7,066.88 / $7,272.40
| Professional | | $7,066.88 | $7,066.88 | $7,272.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,742.72 / $6,095.93 / $27,719.31
| Facility | | $1,742.72 | $6,095.93 | $27,719.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.21 / $2,930.95 / $6,121.41
| Professional | | $1,747.21 | $2,930.95 | $6,121.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.21 / $2,926.58 / $6,400.73
| Professional | | $1,747.21 | $2,926.58 | $6,400.73 |