- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,981.07 / $6,456.54
| Professional | | $3,311.31 | $3,981.07 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $10,471.29 / $28,840.32
| Facility | | $4,466.84 | $10,471.29 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $7,762.47 / $12,589.25
| Professional | | $5,248.07 | $7,762.47 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $11,748.98 / $28,183.83
| Facility | | $8,317.64 | $11,748.98 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,000.00 / $15,135.61
| Professional | | $6,606.93 | $10,000.00 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $11,220.18 / $21,877.62
| Facility | | $9,120.11 | $11,220.18 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $8,511.38 / $12,882.50
| Professional | | $6,025.60 | $8,511.38 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,786.30 / $8,317.64
| Facility | | $2,187.76 | $4,786.30 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $7,244.36 / $18,620.87
| Professional | | $3,981.07 | $7,244.36 | $18,620.87 |
- 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
- $4,073.80 / $6,918.31 / $13,803.84
| Professional | | $4,073.80 | $6,918.31 | $13,803.84 |