- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,082.33 / $6,082.33 / $6,082.33
| Facility | | $6,082.33 | $6,082.33 | $6,082.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,453.75 / $6,082.33 / $6,082.33
| Professional | | $3,453.75 | $6,082.33 | $6,082.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,220.57 / $7,261.64 / $10,111.61
| Facility | | $6,220.57 | $7,261.64 | $10,111.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,809.31 / $6,898.56 / $7,261.64
| Professional | | $5,809.31 | $6,898.56 | $7,261.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,697.47 / $22,405.25 / $62,228.68
| Facility | | $4,697.47 | $22,405.25 | $62,228.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,418.37 / $8,923.48 / $10,691.34
| Professional | | $8,418.37 | $8,923.48 | $10,691.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,301.73 / $21,496.74 / $48,998.96
| Facility | | $13,301.73 | $21,496.74 | $48,998.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,418.37 / $8,418.37 / $8,662.79
| Professional | | $8,418.37 | $8,418.37 | $8,662.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,334.64 / $7,261.64 / $35,737.98
| Facility | | $2,334.64 | $7,261.64 | $35,737.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,340.66 / $3,683.87 / $7,570.82
| Professional | | $2,340.66 | $3,683.87 | $7,570.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,340.66 / $3,622.75 / $9,440.12
| Professional | | $2,340.66 | $3,622.75 | $9,440.12 |