- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $10,715.19 / $10,715.19
| Professional | | $8,128.31 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,011.87 / $5,128.61
| Professional | | $4,265.80 | $5,011.87 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $4,466.84 / $8,128.31
| Facility | | $1,000.00 | $4,466.84 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $6,456.54 / $10,715.19
| Professional | | $60.26 | $6,456.54 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,000.00 / $10,000.00
| Facility | | $891.25 | $1,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,258.93 / $10,000.00
| Professional | | $831.76 | $1,258.93 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,623.41 / $8,511.38
| Facility | | $3,890.45 | $5,623.41 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $4,265.80 / $5,128.61
| Professional | | $60.26 | $4,265.80 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $676.08 / $4,570.88
| Facility | | $446.68 | $676.08 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $6,606.93 / $12,022.64
| Professional | | $3,388.44 | $6,606.93 | $12,022.64 |