- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,398.83 / $3,715.35
| Professional | | $1,905.46 | $2,398.83 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,466.84 / $6,456.54
| Facility | | $4,365.16 | $4,466.84 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,466.84 / $4,466.84
| Professional | | $3,548.13 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $16,595.87 / $39,810.72
| Facility | | $9,549.93 | $16,595.87 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,888.44 / $6,456.54
| Professional | | $5,128.61 | $5,888.44 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,882.50 / $16,595.87 / $30,902.95
| Facility | | $12,882.50 | $16,595.87 | $30,902.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $6,918.31
| Professional | | $5,128.61 | $5,128.61 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $4,466.84 / $8,128.31
| Facility | | $1,905.46 | $4,466.84 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,949.84 / $4,786.30
| Professional | | $1,318.26 | $1,949.84 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.62 / $2,630.27 / $5,370.32
| Facility | | $31.62 | $2,630.27 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,187.76 / $5,128.61
| Professional | | $1,318.26 | $2,187.76 | $5,128.61 |