- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,818.38 / $4,168.69
| Professional | | $2,137.96 | $2,818.38 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $10,000.00 / $34,673.69
| Facility | | $4,897.79 | $10,000.00 | $34,673.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,623.41 / $8,709.64
| Professional | | $4,073.80 | $5,623.41 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $8,128.31 / $19,498.45
| Facility | | $5,754.40 | $8,128.31 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,918.31 / $10,471.29
| Professional | | $4,570.88 | $6,918.31 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $7,762.47 / $15,135.61
| Facility | | $6,309.57 | $7,762.47 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,888.44 / $8,709.64
| Professional | | $4,365.16 | $5,888.44 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,890.45 / $6,760.83
| Facility | | $2,398.83 | $3,890.45 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,786.30 / $10,000.00
| Professional | | $2,570.40 | $4,786.30 | $10,000.00 |
- 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
- $2,570.40 / $4,786.30 / $9,549.93
| Professional | | $2,570.40 | $4,786.30 | $9,549.93 |