- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $10,000.00 / $10,000.00
| Facility | | $4,786.30 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,466.84 / $4,466.84
| Professional | | $2,454.71 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $7,762.47 / $13,182.57
| Facility | | $3,467.37 | $7,762.47 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $2,691.53
| Professional | | $1,148.15 | $1,148.15 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,778.28 / $7,079.46
| Facility | | $1,445.44 | $1,778.28 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,630.27 / $3,981.07
| Professional | | $1,258.93 | $2,630.27 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $4,897.79
| Professional | | $3,801.89 | $3,890.45 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,691.53 / $2,691.53
| Professional | | $1,905.46 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,621.81
| Professional | | $1,148.15 | $1,148.15 | $1,621.81 |