- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $6,760.83
| Facility | | $2,754.23 | $2,754.23 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,951.21 / $4,570.88
| Professional | | $2,570.40 | $2,951.21 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,754.40 / $22,908.68
| Facility | | $2,511.89 | $5,754.40 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,760.83 / $10,232.93
| Professional | | $4,466.84 | $6,760.83 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $10,000.00 / $23,988.33
| Facility | | $7,079.46 | $10,000.00 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $8,128.31 / $12,022.64
| Professional | | $4,897.79 | $8,128.31 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $9,772.37 / $18,620.87
| Facility | | $7,762.47 | $9,772.37 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $6,760.83 / $10,964.78
| Professional | | $5,248.07 | $6,760.83 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,466.84 / $8,128.31
| Facility | | $2,884.03 | $4,466.84 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,370.32 / $15,488.17
| Professional | | $2,691.53 | $5,370.32 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $6,309.57 / $12,589.25
| Facility | | $3,235.94 | $6,309.57 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,011.87 / $10,000.00
| Professional | | $2,754.23 | $5,011.87 | $10,000.00 |