- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $6,760.83 / $26,302.68
| Facility | | $2,137.96 | $6,760.83 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,128.61 / $16,218.10
| Professional | | $2,187.76 | $5,128.61 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,548.13 / $4,265.80
| Facility | | $3,162.28 | $3,548.13 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Professional | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $6,606.93 / $25,118.86
| Facility | | $3,235.94 | $6,606.93 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $5,128.61 / $15,848.93
| Professional | | $1,288.25 | $5,128.61 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,623.41 / $10,000.00
| Facility | | $5,128.61 | $5,623.41 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $79.43
| Professional | | $79.43 | $79.43 | $79.43 |