- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.11 / $2,754.11 / $2,754.11
| Facility | | $2,754.11 | $2,754.11 | $2,754.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.11 / $3,233.35 / $4,050.36
| Professional | | $2,754.11 | $3,233.35 | $4,050.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,293.17 / $11,380.32 / $22,805.03
| Facility | | $5,293.17 | $11,380.32 | $22,805.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,238.76 / $6,473.48 / $9,807.36
| Professional | | $4,238.76 | $6,473.48 | $9,807.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,098.83 / $8,648.90 / $20,806.11
| Facility | | $6,098.83 | $8,648.90 | $20,806.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,938.75 / $8,037.81 / $11,656.82
| Professional | | $4,938.75 | $8,037.81 | $11,656.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,957.91 / $7,907.17 / $16,382.76
| Facility | | $4,957.91 | $7,907.17 | $16,382.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,127.25 / $6,624.23 / $9,860.78
| Professional | | $4,127.25 | $6,624.23 | $9,860.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,644.70 / $4,356.00 / $6,845.11
| Facility | | $2,644.70 | $4,356.00 | $6,845.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,156.43 / $5,788.12 / $11,410.01
| Professional | | $3,156.43 | $5,788.12 | $11,410.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $3,500.00 / $8,152.00
| Facility | | $1,751.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,418.93 / $6,792.07 / $10,839.64
| Professional | | $3,418.93 | $6,792.07 | $10,839.64 |