- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,090.30 / $5,370.32
| Professional | | $2,691.53 | $3,090.30 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $12,022.64 / $40,738.03
| Facility | | $5,888.44 | $12,022.64 | $40,738.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,918.31 / $10,471.29
| Professional | | $4,897.79 | $6,918.31 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $10,000.00 / $23,988.33
| Facility | | $7,079.46 | $10,000.00 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $8,709.64 / $12,882.50
| Professional | | $5,623.41 | $8,709.64 | $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 / $3,981.07 / $7,762.47
| Facility | | $2,691.53 | $3,981.07 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,888.44 / $12,589.25
| Professional | | $3,311.31 | $5,888.44 | $12,589.25 |
- 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
- $3,311.31 / $5,754.40 / $11,220.18
| Professional | | $3,311.31 | $5,754.40 | $11,220.18 |