- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $9,772.37 / $12,022.64
| Facility | | $6,165.95 | $9,772.37 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,165.95 / $9,772.37 / $12,882.50
| Professional | | $6,165.95 | $9,772.37 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $30,199.52
| Facility | | $1,071.52 | $1,071.52 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $8,128.31 / $15,488.17
| Professional | | $6,025.60 | $8,128.31 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Facility | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $10,000.00 / $23,988.33
| Professional | | $1,230.27 | $10,000.00 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,659.59 / $7,244.36
| Facility | | $501.19 | $1,659.59 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,248.07 / $8,511.38
| Professional | | $3,548.13 | $5,248.07 | $8,511.38 |