- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,394.51 / $6,394.51 / $6,394.51
| Facility | | $6,394.51 | $6,394.51 | $6,394.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,597.49 / $6,275.66 / $6,394.51
| Professional | | $3,597.49 | $6,275.66 | $6,394.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,539.84 / $7,634.35 / $10,630.58
| Facility | | $6,539.84 | $7,634.35 | $10,630.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,107.48 / $7,252.63 / $7,634.35
| Professional | | $6,107.48 | $7,252.63 | $7,634.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,938.58 / $23,555.67 / $65,423.88
| Facility | | $4,938.58 | $23,555.67 | $65,423.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,850.37 / $9,381.40 / $11,239.98
| Professional | | $8,850.37 | $9,381.40 | $11,239.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,984.72 / $22,600.51 / $51,514.86
| Facility | | $13,984.72 | $22,600.51 | $51,514.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,850.37 / $8,850.37 / $9,107.60
| Professional | | $8,850.37 | $8,850.37 | $9,107.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,364.13 / $7,634.35 / $37,094.85
| Facility | | $2,364.13 | $7,634.35 | $37,094.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,370.23 / $3,821.95 / $7,666.47
| Professional | | $2,370.23 | $3,821.95 | $7,666.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,783.81 / $5,925.59 / $14,810.82
| Professional | | $2,783.81 | $5,925.59 | $14,810.82 |