- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,691.53 / $7,585.78
| Facility | | $2,137.96 | $2,691.53 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,230.27 / $2,137.96
| Professional | | $977.24 | $1,230.27 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,344.23 / $4,897.79
| Facility | | $1,258.93 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,548.82 / $2,570.40
| Professional | | $1,122.02 | $1,548.82 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,584.89 / $2,344.23
| Professional | | $1,047.13 | $1,584.89 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $10,000.00 / $10,000.00
| Facility | | $54.95 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,471.29 / $10,471.29 / $10,471.29
| Professional | | $10,471.29 | $10,471.29 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,630.27 / $4,786.30
| Facility | | $1,258.93 | $2,630.27 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,548.82 / $2,344.23
| Professional | | $1,000.00 | $1,548.82 | $2,344.23 |