- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $495.57 / $1,000.00 / $3,702.26
| Facility | | $495.57 | $1,000.00 | $3,702.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,154.80 / $5,066.80
| Professional | | $1,000.00 | $3,154.80 | $5,066.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,085.71 / $4,202.14 / $13,170.57
| Facility | | $4,085.71 | $4,202.14 | $13,170.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,533.74 / $5,492.49 / $8,745.58
| Professional | | $4,533.74 | $5,492.49 | $8,745.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,780.00 / $5,497.00 / $19,359.00
| Facility | | $4,780.00 | $5,497.00 | $19,359.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,065.39 / $5,156.68 / $5,729.64
| Professional | | $4,065.39 | $5,156.68 | $5,729.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,007.60 / $2,007.60 / $2,868.00
| Professional | | $2,007.60 | $2,007.60 | $2,868.00 |