- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,677.35 / $10,471.29
| Facility | | $3,467.37 | $4,677.35 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,949.84 / $3,801.89
| Professional | | $1,737.80 | $1,949.84 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $11,748.98 / $13,803.84
| Facility | | $5,370.32 | $11,748.98 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,630.78 / $4,897.79
| Professional | | $1,737.80 | $3,630.78 | $4,897.79 |
- 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
- $1,513.56 / $2,818.38 / $5,495.41
| Professional | | $1,513.56 | $2,818.38 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,818.38 / $3,467.37
| Professional | | $2,089.30 | $2,818.38 | $3,467.37 |
- 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
- $1,659.59 / $2,398.83 / $5,495.41
| Professional | | $1,659.59 | $2,398.83 | $5,495.41 |