- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $10,000.00
| Facility | | $2,398.83 | $3,235.94 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,884.03 / $3,801.89
| Professional | | $2,398.83 | $2,884.03 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,890.45 / $4,677.35
| Facility | | $2,570.40 | $3,890.45 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $3,630.78
| Professional | | $1,445.44 | $1,445.44 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $7,943.28 / $10,964.78
| Facility | | $5,623.41 | $7,943.28 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $18,620.87
| Professional | | $2,818.38 | $2,818.38 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,677.35 / $16,595.87
| Professional | | $3,235.94 | $4,677.35 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,168.69 / $7,585.78
| Professional | | $3,467.37 | $4,168.69 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,630.78
| Facility | | $3,235.94 | $3,235.94 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $5,011.87
| Professional | | $1,513.56 | $2,137.96 | $5,011.87 |