- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Facility | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,511.89 / $4,168.69
| Professional | | $2,238.72 | $2,511.89 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,370.32 / $19,952.62
| Facility | | $2,344.23 | $5,370.32 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,623.41 / $9,120.11
| Professional | | $3,801.89 | $5,623.41 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $9,120.11 / $21,877.62
| Facility | | $6,456.54 | $9,120.11 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $7,762.47 / $11,748.98
| Professional | | $5,128.61 | $7,762.47 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $8,709.64 / $17,378.01
| Facility | | $7,079.46 | $8,709.64 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,606.93 / $10,000.00
| Professional | | $4,677.35 | $6,606.93 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,890.45 / $7,079.46
| Facility | | $2,344.23 | $3,890.45 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,128.61 / $14,454.40
| Professional | | $2,951.21 | $5,128.61 | $14,454.40 |
- 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
- $2,884.03 / $5,011.87 / $10,000.00
| Professional | | $2,884.03 | $5,011.87 | $10,000.00 |