- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,677.35 / $10,471.29
| Facility | | $3,801.89 | $4,677.35 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,884.03 / $5,623.41
| Professional | | $2,511.89 | $2,884.03 | $5,623.41 |
- 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
- $2,454.71 / $5,370.32 / $7,079.46
| Professional | | $2,454.71 | $5,370.32 | $7,079.46 |
- 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
- $2,187.76 / $4,168.69 / $8,317.64
| Professional | | $2,187.76 | $4,168.69 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,073.80 / $5,128.61
| Professional | | $3,090.30 | $4,073.80 | $5,128.61 |
- 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 / $3,467.37 / $7,943.28
| Professional | | $2,454.71 | $3,467.37 | $7,943.28 |