- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $6,760.83
| Facility | | $1,202.26 | $1,202.26 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,202.26 / $1,905.46
| Professional | | $1,047.13 | $1,202.26 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $8,128.31 / $22,908.68
| Facility | | $4,897.79 | $8,128.31 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,818.38 / $4,265.80
| Professional | | $1,862.09 | $2,818.38 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,265.80 / $10,232.93
| Facility | | $3,019.95 | $4,265.80 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,467.37 / $5,128.61
| Professional | | $2,041.74 | $3,467.37 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,073.80 / $8,128.31
| Facility | | $3,311.31 | $4,073.80 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,884.03 / $4,677.35
| Professional | | $2,187.76 | $2,884.03 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,187.76 / $6,918.31
| Facility | | $1,202.26 | $2,187.76 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,187.76 / $6,309.57
| Professional | | $1,096.48 | $2,187.76 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,011.87 / $10,000.00
| Facility | | $2,818.38 | $5,011.87 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,089.30 / $4,168.69
| Professional | | $1,148.15 | $2,089.30 | $4,168.69 |