- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $3,715.35 / $3,715.35
| Facility | | $128.82 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $4,265.80
| Professional | | $3,715.35 | $3,715.35 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,801.89 / $4,570.88
| Facility | | $2,511.89 | $3,801.89 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,981.07 / $4,168.69
| Professional | | $3,890.45 | $3,981.07 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.82 / $223.87 / $309.03
| Facility | | $169.82 | $223.87 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $4,570.88
| Professional | | $3,019.95 | $3,715.35 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,265.80 / $7,244.36
| Facility | | $3,548.13 | $4,265.80 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,801.89 / $4,168.69
| Professional | | $2,951.21 | $3,801.89 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,466.84 / $4,570.88
| Professional | | $3,548.13 | $4,466.84 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.82 / $208.93 / $309.03
| Facility | | $169.82 | $208.93 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $9,332.54 / $9,332.54
| Professional | | $4,466.84 | $9,332.54 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,786.30 / $7,762.47
| Facility | | $2,951.21 | $4,786.30 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $2,818.38 / $2,951.21
| Professional | | $125.89 | $2,818.38 | $2,951.21 |