- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,890.45 / $7,943.28
| Facility | | $2,041.74 | $3,890.45 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,621.81 / $4,466.84
| Professional | | $1,412.54 | $1,621.81 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $5,370.32 / $7,943.28
| Facility | | $1,659.59 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,445.44 / $4,466.84
| Professional | | $1,380.38 | $1,445.44 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,698.24 / $2,454.71
| Professional | | $1,412.54 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,089.30 / $5,128.61
| Facility | | $1,412.54 | $2,089.30 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,737.80 / $10,000.00
| Professional | | $1,348.96 | $1,737.80 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,290.87 / $5,495.41
| Facility | | $1,348.96 | $2,290.87 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,584.89 / $2,511.89
| Professional | | $1,318.26 | $1,584.89 | $2,511.89 |