- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,623.41 / $10,471.29
| Facility | | $4,570.88 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,981.07 / $7,585.78
| Professional | | $3,388.44 | $3,981.07 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $16,218.10 / $18,620.87
| Facility | | $8,709.64 | $16,218.10 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $7,079.46 / $9,772.37
| Professional | | $3,388.44 | $7,079.46 | $9,772.37 |
- 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
- $3,162.28 / $6,025.60 / $11,220.18
| Professional | | $3,162.28 | $6,025.60 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,754.40 / $7,079.46
| Professional | | $4,466.84 | $5,754.40 | $7,079.46 |
- 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
- $3,388.44 / $5,011.87 / $10,715.19
| Professional | | $3,388.44 | $5,011.87 | $10,715.19 |