- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,897.79 / $10,471.29
| Facility | | $4,570.88 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,691.53 / $5,128.61
| Professional | | $2,290.87 | $2,691.53 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $15,848.93 / $16,595.87
| Facility | | $8,317.64 | $15,848.93 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,897.79 / $6,760.83
| Professional | | $2,290.87 | $4,897.79 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,801.89 / $7,762.47
| Professional | | $2,137.96 | $3,801.89 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,890.45 / $4,786.30
| Professional | | $2,754.23 | $3,890.45 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $4,786.30 / $10,000.00
| Facility | | $758.58 | $4,786.30 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,235.94 / $7,413.10
| Professional | | $2,290.87 | $3,235.94 | $7,413.10 |