- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,623.41 / $10,471.29
| Facility | | $2,344.23 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,778.28 / $2,344.23
| Professional | | $1,258.93 | $1,778.28 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,137.96 / $3,019.95
| Professional | | $1,548.82 | $2,137.96 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $1,995.26 / $4,897.79
| Facility | | $54.95 | $1,995.26 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,949.84 / $10,000.00
| Professional | | $1,445.44 | $1,949.84 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,445.44 / $5,623.41
| Facility | | $851.14 | $1,445.44 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,949.84 / $2,570.40
| Professional | | $1,513.56 | $1,949.84 | $2,570.40 |