- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,585.78 / $9,332.54
| Facility | | $4,786.30 | $7,585.78 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,413.10 / $10,000.00
| Professional | | $4,786.30 | $7,413.10 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $23,442.29
| Facility | | $831.76 | $831.76 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $6,309.57 / $12,022.64
| Professional | | $3,311.31 | $6,309.57 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $6,165.95
| Facility | | $5,011.87 | $5,011.87 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,011.87 / $18,620.87
| Professional | | $4,265.80 | $5,011.87 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $1,288.25 / $5,623.41
| Facility | | $389.05 | $1,288.25 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,073.80 / $6,918.31
| Professional | | $2,754.23 | $4,073.80 | $6,918.31 |