- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,897.79 / $8,511.38
| Facility | | $1,122.02 | $4,897.79 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,148.15 / $1,737.80
| Professional | | $912.01 | $1,148.15 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,897.79 / $10,000.00
| Facility | | $2,238.72 | $4,897.79 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,288.25 / $1,949.84
| Professional | | $1,023.29 | $1,288.25 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $977.24 / $1,445.44
| Professional | | $812.83 | $977.24 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,380.38 / $2,511.89
| Professional | | $776.25 | $1,380.38 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $1,778.28 / $11,220.18
| Facility | | $54.95 | $1,778.28 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,621.81 / $10,471.29
| Professional | | $891.25 | $1,621.81 | $10,471.29 |
- 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
- $891.25 / $1,445.44 / $2,398.83
| Professional | | $891.25 | $1,445.44 | $2,398.83 |