- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,206.23 / $2,206.23 / $2,206.23
| Facility | | $2,206.23 | $2,206.23 | $2,206.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,206.23 / $2,578.87 / $3,220.96
| Professional | | $2,206.23 | $2,578.87 | $3,220.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $988.21 / $2,074.00 / $16,155.09
| Facility | | $988.21 | $2,074.00 | $16,155.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,396.16 / $5,203.32 / $7,831.03
| Professional | | $3,396.16 | $5,203.32 | $7,831.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,890.18 / $6,934.89 / $16,682.82
| Facility | | $4,890.18 | $6,934.89 | $16,682.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,974.11 / $6,467.87 / $9,380.01
| Professional | | $3,974.11 | $6,467.87 | $9,380.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,975.37 / $6,340.15 / $13,136.08
| Facility | | $3,975.37 | $6,340.15 | $13,136.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,321.11 / $5,330.38 / $7,934.78
| Professional | | $3,321.11 | $5,330.38 | $7,934.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,976.33 / $3,500.00 / $5,443.42
| Facility | | $1,976.33 | $3,500.00 | $5,443.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,491.87 / $4,569.06 / $9,038.20
| Professional | | $2,491.87 | $4,569.06 | $9,038.20 |
- 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
- $2,648.24 / $5,403.53 / $8,687.95
| Professional | | $2,648.24 | $5,403.53 | $8,687.95 |