- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,897.79 / $8,511.38
| Facility | | $1,584.89 | $4,897.79 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $2,238.72
| Professional | | $1,230.27 | $1,584.89 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,677.35 / $10,000.00
| Facility | | $2,238.72 | $4,677.35 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,737.80 / $2,884.03
| Professional | | $1,412.54 | $1,737.80 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,412.54 / $2,137.96
| Professional | | $1,230.27 | $1,412.54 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,949.84 / $3,548.13
| Professional | | $1,122.02 | $1,949.84 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,398.83 / $11,748.98
| Facility | | $54.95 | $2,398.83 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,187.76 / $18,197.01
| Professional | | $1,288.25 | $2,187.76 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,818.38 / $10,471.29
| Facility | | $1,288.25 | $2,818.38 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,041.74 / $3,388.44
| Professional | | $1,288.25 | $2,041.74 | $3,388.44 |