- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,819.70 / $2,884.03
| Professional | | $1,445.44 | $1,819.70 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $5,011.87
| Facility | | $3,388.44 | $3,388.44 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,388.44 / $3,388.44
| Professional | | $2,754.23 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $12,882.50 / $30,902.95
| Facility | | $7,413.10 | $12,882.50 | $30,902.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,570.88 / $5,011.87
| Professional | | $3,981.07 | $4,570.88 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $12,882.50 / $23,988.33
| Facility | | $10,000.00 | $12,882.50 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $5,370.32
| Professional | | $3,981.07 | $3,981.07 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,388.44 / $6,165.95
| Facility | | $1,479.11 | $3,388.44 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,513.56 / $3,715.35
| Professional | | $1,023.29 | $1,513.56 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.55 / $2,041.74 / $4,168.69
| Facility | | $24.55 | $2,041.74 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,698.24 / $3,981.07
| Professional | | $1,023.29 | $1,698.24 | $3,981.07 |