- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,677.35 / $10,471.29
| Facility | | $3,388.44 | $4,677.35 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,862.09 / $3,548.13
| Professional | | $1,621.81 | $1,862.09 | $3,548.13 |
- 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
- $1,659.59 / $3,467.37 / $4,677.35
| Professional | | $1,659.59 | $3,467.37 | $4,677.35 |
- 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
- $1,412.54 / $2,691.53 / $5,495.41
| Professional | | $1,412.54 | $2,691.53 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $3,311.31
| Professional | | $1,995.26 | $2,691.53 | $3,311.31 |
- 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
- $1,548.82 / $2,238.72 / $5,128.61
| Professional | | $1,548.82 | $2,238.72 | $5,128.61 |