- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,248.07 / $10,471.29
| Facility | | $4,570.88 | $5,248.07 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,019.95 / $5,754.40
| Professional | | $2,511.89 | $3,019.95 | $5,754.40 |
- 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
- $2,570.40 / $5,370.32 / $7,413.10
| Professional | | $2,570.40 | $5,370.32 | $7,413.10 |
- 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
- $2,454.71 / $4,168.69 / $8,511.38
| Professional | | $2,454.71 | $4,168.69 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,365.16 / $5,370.32
| Professional | | $3,235.94 | $4,365.16 | $5,370.32 |
- 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
- $2,454.71 / $3,548.13 / $8,317.64
| Professional | | $2,454.71 | $3,548.13 | $8,317.64 |