- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,897.79 / $10,471.29
| Facility | | $4,570.88 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,691.53 / $5,011.87
| Professional | | $2,238.72 | $2,691.53 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $11,748.98 / $13,803.84
| Facility | | $7,413.10 | $11,748.98 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,677.35 / $6,309.57
| Professional | | $2,238.72 | $4,677.35 | $6,309.57 |
- 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
- $2,041.74 / $3,630.78 / $7,413.10
| Professional | | $2,041.74 | $3,630.78 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,801.89 / $4,897.79
| Professional | | $2,818.38 | $3,801.89 | $4,897.79 |
- 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
- $2,137.96 / $3,162.28 / $7,244.36
| Professional | | $2,137.96 | $3,162.28 | $7,244.36 |