- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,602.89 / $3,602.89 / $3,602.89
| Facility | | $3,602.89 | $3,602.89 | $3,602.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,608.47 / $2,987.46 / $3,602.89
| Professional | | $1,608.47 | $2,987.46 | $3,602.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,684.77 / $4,301.46 / $5,989.64
| Facility | | $3,684.77 | $4,301.46 | $5,989.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,441.17 / $4,086.39 / $4,301.46
| Professional | | $3,441.17 | $4,086.39 | $4,301.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,782.58 / $13,272.24 / $36,862.53
| Facility | | $2,782.58 | $13,272.24 | $36,862.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,986.75 / $5,285.96 / $6,333.17
| Professional | | $4,986.75 | $5,285.96 | $6,333.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,879.57 / $12,734.07 / $29,025.61
| Facility | | $7,879.57 | $12,734.07 | $29,025.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,986.75 / $4,986.75 / $5,131.60
| Professional | | $4,986.75 | $4,986.75 | $5,131.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,125.42 / $4,301.46 / $17,790.55
| Facility | | $1,125.42 | $4,301.46 | $17,790.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.32 / $1,889.94 / $4,319.43
| Professional | | $1,128.32 | $1,889.94 | $4,319.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.32 / $1,788.29 / $4,319.43
| Professional | | $1,128.32 | $1,788.29 | $4,319.43 |