- 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
- $2,290.87 / $2,630.27 / $4,786.30
| Professional | | $2,290.87 | $2,630.27 | $4,786.30 |
- 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
- $2,570.40 / $3,548.13 / $5,495.41
| Professional | | $2,570.40 | $3,548.13 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,570.40 / $2,884.03
| Facility | | $2,344.23 | $2,570.40 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,388.44 / $5,754.40
| Professional | | $2,570.40 | $3,388.44 | $5,754.40 |
- 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
- $2,137.96 / $2,884.03 / $5,011.87
| Professional | | $2,137.96 | $2,884.03 | $5,011.87 |