- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,238.72 / $2,238.72
| Facility | | $1,412.54 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,344.23 / $2,691.53
| Professional | | $2,187.76 | $2,344.23 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,818.38
| Facility | | $2,238.72 | $2,238.72 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Professional | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $3,630.78 / $3,630.78
| Facility | | $34.67 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,311.31 / $10,000.00
| Professional | | $1,778.28 | $3,311.31 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,905.46 / $3,467.37
| Professional | | $1,288.25 | $1,905.46 | $3,467.37 |