- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,162.28 / $4,265.80
| Professional | | $2,630.27 | $3,162.28 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $16,982.44 / $36,307.81
| Facility | | $7,762.47 | $16,982.44 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,606.93 / $10,715.19
| Professional | | $4,466.84 | $6,606.93 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,471.29 / $25,118.86
| Facility | | $7,413.10 | $10,471.29 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $8,912.51 / $13,489.63
| Professional | | $5,888.44 | $8,912.51 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $10,000.00 / $19,498.45
| Facility | | $7,943.28 | $10,000.00 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $7,413.10 / $11,220.18
| Professional | | $5,370.32 | $7,413.10 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,073.80 / $8,128.31
| Facility | | $2,691.53 | $4,073.80 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,888.44 / $15,848.93
| Professional | | $3,388.44 | $5,888.44 | $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
- $3,311.31 / $5,888.44 / $11,748.98
| Professional | | $3,311.31 | $5,888.44 | $11,748.98 |