- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,623.41 / $10,964.78
| Facility | | $2,570.40 | $5,623.41 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $588.84 / $1,621.81
| Professional | | $323.59 | $588.84 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $758.58 / $2,089.30
| Professional | | $389.05 | $758.58 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,412.54 / $1,949.84
| Professional | | $588.84 | $1,412.54 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,309.57 / $10,000.00
| Facility | | $3,981.07 | $6,309.57 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $660.69 / $2,398.83
| Professional | | $281.84 | $660.69 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,606.93 / $10,964.78
| Facility | | $2,951.21 | $6,606.93 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $602.56 / $1,348.96
| Professional | | $281.84 | $602.56 | $1,348.96 |