- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $7,943.28 / $10,000.00
| Facility | | $6,760.83 | $7,943.28 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,248.07 / $8,128.31
| Professional | | $3,630.78 | $5,248.07 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.88 / $70.79 / $95.50
| Facility | | $58.88 | $70.79 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $602.56 / $4,365.16
| Professional | | $426.58 | $602.56 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,495.41 / $14,454.40
| Facility | | $4,365.16 | $5,495.41 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $6,025.60 / $6,760.83
| Facility | | $2,818.38 | $6,025.60 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $4,073.80
| Professional | | $2,818.38 | $2,818.38 | $4,073.80 |