- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $8,511.38
| Facility | | $3,235.94 | $3,235.94 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,235.94 / $8,128.31
| Professional | | $2,754.23 | $3,235.94 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $7,079.46 / $8,511.38
| Professional | | $5,754.40 | $7,079.46 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,025.60 / $10,000.00
| Professional | | $3,715.35 | $6,025.60 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,890.45 / $6,760.83
| Facility | | $3,235.94 | $3,890.45 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,888.44 / $23,988.33
| Professional | | $3,467.37 | $5,888.44 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,888.44 / $14,125.38
| Facility | | $5,370.32 | $5,888.44 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,888.44 / $7,943.28
| Professional | | $3,467.37 | $5,888.44 | $7,943.28 |