- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Facility | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,786.30 / $38,904.51
| Professional | | $2,570.40 | $4,786.30 | $38,904.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $6,760.83
| Professional | | $4,786.30 | $4,786.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $7,079.46 / $9,120.11
| Professional | | $60.26 | $7,079.46 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $8,511.38 / $14,791.08
| Facility | | $7,244.36 | $8,511.38 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $6,918.31 / $10,000.00
| Professional | | $5,370.32 | $6,918.31 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,709.64 / $9,772.37 / $10,000.00
| Professional | | $8,709.64 | $9,772.37 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $10,000.00 / $11,481.54
| Professional | | $7,079.46 | $10,000.00 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,466.84 / $6,025.60
| Facility | | $3,311.31 | $4,466.84 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,981.07 / $6,025.60
| Professional | | $3,162.28 | $3,981.07 | $6,025.60 |