- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,810.22 / $4,810.22 / $4,810.22
| Facility | | $4,810.22 | $4,810.22 | $4,810.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,651.18 / $4,518.89 / $4,810.22
| Professional | | $2,651.18 | $4,518.89 | $4,810.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $6,129.76 / $8,074.68
| Facility | | $1.00 | $6,129.76 | $8,074.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,594.30 / $5,455.74 / $5,742.88
| Professional | | $4,594.30 | $5,455.74 | $5,742.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,536.46 / $17,719.77 / $49,215.17
| Facility | | $4,536.46 | $17,719.77 | $49,215.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,657.75 / $7,057.22 / $8,455.34
| Professional | | $6,657.75 | $7,057.22 | $8,455.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,520.02 / $17,001.25 / $38,752.10
| Facility | | $10,520.02 | $17,001.25 | $38,752.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,657.75 / $6,657.75 / $6,851.20
| Professional | | $6,657.75 | $6,657.75 | $6,851.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,702.33 / $5,742.88 / $26,749.15
| Facility | | $1,702.33 | $5,742.88 | $26,749.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,706.73 / $2,863.04 / $5,766.89
| Professional | | $1,706.73 | $2,863.04 | $5,766.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,706.73 / $2,864.19 / $10,664.77
| Professional | | $1,706.73 | $2,864.19 | $10,664.77 |