- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,388.44 / $3,890.45
| Facility | | $1,949.84 | $3,388.44 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,737.80 / $2,187.76
| Professional | | $1,348.96 | $1,737.80 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $1,148.15 / $3,235.94
| Professional | | $302.00 | $1,148.15 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,890.45 / $4,786.30
| Facility | | $2,630.27 | $3,890.45 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Professional | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,454.71 / $9,549.93
| Facility | | $1,778.28 | $2,454.71 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,230.27 / $10,000.00
| Professional | | $851.14 | $1,230.27 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $2,041.74 / $2,454.71
| Facility | | $851.14 | $2,041.74 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,230.27 / $2,238.72
| Professional | | $851.14 | $1,230.27 | $2,238.72 |