- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,570.88 / $10,471.29
| Facility | | $2,398.83 | $4,570.88 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $2,884.03
| Professional | | $1,513.56 | $2,137.96 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,398.83 / $3,388.44
| Professional | | $1,905.46 | $2,398.83 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $3,235.94 / $10,000.00
| Facility | | $54.95 | $3,235.94 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $12,302.69
| Professional | | $1,778.28 | $2,344.23 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,623.41 / $10,715.19
| Facility | | $2,818.38 | $5,623.41 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,238.72 / $3,019.95
| Professional | | $1,778.28 | $2,238.72 | $3,019.95 |