- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,951.21 / $22,387.21
| Professional | | $2,344.23 | $2,951.21 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,466.84 / $4,570.88
| Professional | | $4,073.80 | $4,466.84 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $5,248.07
| Facility | | $2,818.38 | $2,818.38 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,888.44 / $8,511.38
| Professional | | $2,818.38 | $5,888.44 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,128.61 / $23,442.29
| Facility | | $2,951.21 | $5,128.61 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,951.21 / $4,786.30
| Professional | | $1,548.82 | $2,951.21 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,456.54 / $11,481.54
| Professional | | $5,128.61 | $6,456.54 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Facility | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $8,511.38 / $11,481.54
| Professional | | $6,456.54 | $8,511.38 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,019.95 / $3,715.35
| Facility | | $1,288.25 | $3,019.95 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,290.87 / $3,630.78
| Professional | | $1,778.28 | $2,290.87 | $3,630.78 |