- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,897.79 / $14,125.38
| Facility | | $1,380.38 | $4,897.79 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,513.56 / $3,235.94
| Professional | | $1,380.38 | $1,513.56 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $19,952.62 / $27,542.29
| Facility | | $8,317.64 | $19,952.62 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,621.81 / $2,754.23
| Professional | | $1,288.25 | $1,621.81 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,548.82 / $1,778.28
| Facility | | $1,412.54 | $1,548.82 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $3,388.44
| Professional | | $1,412.54 | $1,905.46 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $10,000.00 / $18,197.01
| Facility | | $4,466.84 | $10,000.00 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,659.59 / $2,884.03
| Professional | | $1,288.25 | $1,659.59 | $2,884.03 |