- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,011.87 / $5,011.87
| Facility | | $4,365.16 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $3,630.78 / $5,370.32
| Professional | | $100.00 | $3,630.78 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $10,715.19 / $27,542.29
| Facility | | $6,025.60 | $10,715.19 | $27,542.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,897.79 / $9,332.54
| Facility | | $3,311.31 | $4,897.79 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,248.07 / $10,000.00
| Facility | | $2,884.03 | $5,248.07 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $186.21
| Professional | | $186.21 | $186.21 | $186.21 |