- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,897.79 / $10,471.29
| Facility | | $2,691.53 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $2,884.03
| Professional | | $1,258.93 | $1,513.56 | $2,884.03 |
- 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
- $1,258.93 / $2,691.53 / $3,715.35
| Professional | | $1,258.93 | $2,691.53 | $3,715.35 |
- 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
- $1,202.26 / $2,089.30 / $4,365.16
| Professional | | $1,202.26 | $2,089.30 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,187.76 / $2,691.53
| Professional | | $1,584.89 | $2,187.76 | $2,691.53 |
- 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
- $1,202.26 / $1,778.28 / $4,073.80
| Professional | | $1,202.26 | $1,778.28 | $4,073.80 |