- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,309.57 / $7,585.78
| Facility | | $3,890.45 | $6,309.57 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,165.95 / $8,128.31
| Professional | | $3,890.45 | $6,165.95 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $19,498.45
| Facility | | $691.83 | $691.83 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,128.61 / $10,000.00
| Professional | | $3,235.94 | $5,128.61 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $4,365.16
| Facility | | $3,801.89 | $3,801.89 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,801.89 / $15,135.61
| Professional | | $3,235.94 | $3,801.89 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,071.52 / $4,677.35
| Facility | | $316.23 | $1,071.52 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,311.31 / $5,248.07
| Professional | | $2,290.87 | $3,311.31 | $5,248.07 |