- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,248.07 / $7,943.28
| Facility | | $2,398.83 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,584.89 / $3,801.89
| Professional | | $1,288.25 | $1,584.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,467.37 / $4,365.16
| Professional | | $2,691.53 | $3,467.37 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,089.30 / $8,912.51
| Professional | | $1,380.38 | $2,089.30 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,388.44 / $10,000.00
| Facility | | $1,819.70 | $3,388.44 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,884.03 / $15,848.93
| Professional | | $1,513.56 | $2,884.03 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,467.37 / $4,073.80
| Professional | | $2,951.21 | $3,467.37 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $4,073.80
| Professional | | $2,754.23 | $2,754.23 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,964.78 / $15,848.93
| Facility | | $7,413.10 | $10,964.78 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,187.76 / $4,265.80
| Professional | | $1,445.44 | $2,187.76 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,951.21 / $3,467.37
| Professional | | $2,344.23 | $2,951.21 | $3,467.37 |