- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,897.79 / $10,471.29
| Facility | | $3,981.07 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,238.72 / $4,265.80
| Professional | | $1,905.46 | $2,238.72 | $4,265.80 |
- 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
- $1,862.09 / $3,981.07 / $5,623.41
| Professional | | $1,862.09 | $3,981.07 | $5,623.41 |
- 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
- $1,778.28 / $3,019.95 / $6,309.57
| Professional | | $1,778.28 | $3,019.95 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,235.94 / $3,981.07
| Professional | | $2,344.23 | $3,235.94 | $3,981.07 |
- 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
- $1,778.28 / $2,630.27 / $6,165.95
| Professional | | $1,778.28 | $2,630.27 | $6,165.95 |