- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,467.37 / $5,495.41
| Professional | | $2,691.53 | $3,467.37 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,456.54 / $9,549.93
| Facility | | $6,309.57 | $6,456.54 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $6,456.54 / $6,456.54
| Professional | | $5,248.07 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,125.38 / $24,547.09 / $58,884.37
| Facility | | $14,125.38 | $24,547.09 | $58,884.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $8,511.38 / $9,549.93
| Professional | | $7,585.78 | $8,511.38 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,620.87 / $23,988.33 / $45,708.82
| Facility | | $18,620.87 | $23,988.33 | $45,708.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $10,232.93
| Professional | | $7,585.78 | $7,585.78 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $6,456.54 / $13,182.57
| Facility | | $2,691.53 | $6,456.54 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,884.03 / $6,918.31
| Professional | | $1,905.46 | $2,884.03 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.71 / $3,801.89 / $7,762.47
| Facility | | $45.71 | $3,801.89 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,162.28 / $7,585.78
| Professional | | $1,905.46 | $3,162.28 | $7,585.78 |