- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $6,309.57 / $13,489.63
| Facility | | $933.25 | $6,309.57 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,047.13 / $3,630.78
| Professional | | $912.01 | $1,047.13 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,344.23 / $2,884.03
| Professional | | $2,041.74 | $2,344.23 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $2,818.38
| Facility | | $1,202.26 | $1,445.44 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,905.46 / $10,000.00
| Professional | | $891.25 | $1,905.46 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $2,290.87
| Professional | | $1,905.46 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,698.24 / $1,995.26
| Professional | | $1,071.52 | $1,698.24 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,778.28 / $2,818.38
| Professional | | $912.01 | $1,778.28 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $2,398.83
| Professional | | $1,949.84 | $1,949.84 | $2,398.83 |