- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,897.79 / $10,471.29
| Facility | | $3,715.35 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,137.96 / $3,981.07
| Professional | | $1,778.28 | $2,137.96 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $12,302.69 / $13,803.84
| Facility | | $6,760.83 | $12,302.69 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,715.35 / $5,128.61
| Professional | | $1,778.28 | $3,715.35 | $5,128.61 |
- 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
- $1,698.24 / $2,884.03 / $5,888.44
| Professional | | $1,698.24 | $2,884.03 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,019.95 / $3,715.35
| Professional | | $2,187.76 | $3,019.95 | $3,715.35 |
- 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
- $1,737.80 / $2,511.89 / $5,754.40
| Professional | | $1,737.80 | $2,511.89 | $5,754.40 |