- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $12,022.64 / $16,595.87
| Facility | | $3,801.89 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,659.59 / $7,079.46
| Professional | | $1,288.25 | $1,659.59 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,265.80
| Professional | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,862.09 / $10,000.00
| Facility | | $1,513.56 | $1,862.09 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,890.45 / $8,511.38
| Professional | | $3,019.95 | $3,890.45 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,128.61 / $7,079.46
| Professional | | $4,786.30 | $5,128.61 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $7,079.46 / $10,000.00
| Facility | | $1,862.09 | $7,079.46 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $1,230.27 / $4,265.80
| Professional | | $60.26 | $1,230.27 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,128.61 / $7,943.28
| Professional | | $1,698.24 | $5,128.61 | $7,943.28 |