- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $12,022.64 / $16,595.87
| Facility | | $4,570.88 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,737.80 / $7,244.36
| Professional | | $1,380.38 | $1,737.80 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Professional | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $10,000.00
| Facility | | $1,513.56 | $2,137.96 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,570.88 / $10,471.29
| Professional | | $3,548.13 | $4,570.88 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $8,912.51
| Professional | | $6,165.95 | $6,165.95 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $7,244.36 / $10,232.93
| Facility | | $2,137.96 | $7,244.36 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $1,445.44 / $5,011.87
| Professional | | $60.26 | $1,445.44 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,073.80 / $9,332.54
| Professional | | $3,890.45 | $4,073.80 | $9,332.54 |