- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $7,413.10 / $9,332.54
| Facility | | $6,456.54 | $7,413.10 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $7,413.10 / $10,000.00
| Professional | | $5,370.32 | $7,413.10 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $21,379.62
| Facility | | $870.96 | $870.96 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,606.93 / $11,748.98
| Professional | | $4,897.79 | $6,606.93 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,317.64 / $8,317.64
| Facility | | $8,128.31 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $8,317.64 / $16,595.87
| Professional | | $1,000.00 | $8,317.64 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $1,174.90 / $7,244.36
| Facility | | $524.81 | $1,174.90 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,677.35 / $7,943.28
| Professional | | $3,311.31 | $4,677.35 | $7,943.28 |