- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,818.38 / $4,365.16
| Professional | | $2,398.83 | $2,818.38 | $4,365.16 |
- 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
- $3,715.35 / $5,128.61 / $8,511.38
| Professional | | $3,715.35 | $5,128.61 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $7,943.28 / $19,054.61
| Facility | | $5,623.41 | $7,943.28 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,760.83 / $10,232.93
| Professional | | $4,466.84 | $6,760.83 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $7,585.78 / $14,791.08
| Facility | | $6,165.95 | $7,585.78 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,754.40 / $8,511.38
| Professional | | $4,265.80 | $5,754.40 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,981.07 / $6,606.93
| Facility | | $2,754.23 | $3,981.07 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,786.30 / $10,000.00
| Professional | | $2,951.21 | $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
- $3,090.30 / $4,897.79 / $9,332.54
| Professional | | $3,090.30 | $4,897.79 | $9,332.54 |