- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $7,079.46
| Facility | | $5,011.87 | $5,011.87 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $2,238.72 / $5,370.32
| Professional | | $457.09 | $2,238.72 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,128.61 / $10,000.00
| Facility | | $2,754.23 | $5,128.61 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,818.38 / $2,818.38
| Professional | | $2,754.23 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,754.40 / $10,715.19
| Facility | | $2,137.96 | $5,754.40 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $5,370.32
| Facility | | $2,754.23 | $2,754.23 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,884.03 / $3,467.37
| Professional | | $2,691.53 | $2,884.03 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,370.32 / $10,000.00
| Facility | | $4,168.69 | $5,370.32 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,884.03
| Professional | | $2,344.23 | $2,344.23 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $2,754.23
| Professional | | $1,148.15 | $1,148.15 | $2,754.23 |