- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,709.64 / $15,135.61
| Facility | | $5,128.61 | $8,709.64 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,265.80 / $5,495.41
| Professional | | $3,467.37 | $4,265.80 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,760.83 / $8,128.31
| Facility | | $6,025.60 | $6,760.83 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Professional | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $10,715.19 / $22,908.68
| Facility | | $3,235.94 | $10,715.19 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $6,025.60 / $7,244.36
| Professional | | $5,754.40 | $6,025.60 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $6,760.83 / $9,332.54
| Professional | | $346.74 | $6,760.83 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Professional | | $6,456.54 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $10,000.00
| Facility | | $5,011.87 | $5,011.87 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $5,011.87
| Professional | | $2,089.30 | $3,019.95 | $5,011.87 |