- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $2,398.83 / $9,772.37
| Facility | | $100.00 | $2,398.83 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,073.80 / $5,248.07
| Professional | | $2,290.87 | $4,073.80 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $10,000.00 / $18,197.01
| Facility | | $8,912.51 | $10,000.00 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $10,715.19
| Professional | | $3,235.94 | $7,413.10 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,128.31 / $10,000.00
| Professional | | $5,128.61 | $8,128.31 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,456.54 / $10,000.00
| Professional | | $3,801.89 | $6,456.54 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,456.54 / $12,589.25
| Professional | | $4,677.35 | $6,456.54 | $12,589.25 |