- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,162.28 / $5,248.07
| Professional | | $2,754.23 | $3,162.28 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $17,378.01 / $42,657.95
| Facility | | $7,244.36 | $17,378.01 | $42,657.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,309.57 / $10,000.00
| Professional | | $4,365.16 | $6,309.57 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $10,232.93 / $23,988.33
| Facility | | $7,079.46 | $10,232.93 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $8,511.38 / $12,882.50
| Professional | | $5,623.41 | $8,511.38 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $9,772.37 / $19,054.61
| Facility | | $7,762.47 | $9,772.37 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $7,244.36 / $10,964.78
| Professional | | $5,248.07 | $7,244.36 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,073.80 / $7,762.47
| Facility | | $2,691.53 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,754.40 / $15,848.93
| Professional | | $3,235.94 | $5,754.40 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,467.37 / $8,511.38
| Facility | | $1,584.89 | $3,467.37 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,754.40 / $11,220.18
| Professional | | $3,235.94 | $5,754.40 | $11,220.18 |