- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $8,709.64 / $10,000.00
| Facility | | $6,309.57 | $8,709.64 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,265.80 / $6,606.93
| Professional | | $3,467.37 | $4,265.80 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,162.28 / $8,317.64
| Professional | | $1,905.46 | $3,162.28 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $10,000.00 / $12,589.25
| Facility | | $6,760.83 | $10,000.00 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $6,025.60
| Professional | | $6,025.60 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,309.57 / $24,547.09
| Facility | | $4,570.88 | $6,309.57 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,162.28 / $26,302.68
| Professional | | $2,187.76 | $3,162.28 | $26,302.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,248.07 / $6,309.57
| Facility | | $2,187.76 | $5,248.07 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,162.28 / $5,754.40
| Professional | | $2,187.76 | $3,162.28 | $5,754.40 |