- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,370.32 / $13,182.57
| Facility | | $1,995.26 | $5,370.32 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,290.87 / $4,265.80
| Professional | | $1,949.84 | $2,290.87 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $12,302.69 / $23,988.33
| Facility | | $4,073.80 | $12,302.69 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,454.71 / $4,677.35
| Professional | | $1,737.80 | $2,454.71 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $3,548.13 / $14,791.08
| Facility | | $457.09 | $3,548.13 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,884.03 / $6,025.60
| Professional | | $1,698.24 | $2,884.03 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $2,818.38 / $10,000.00
| Facility | | $537.03 | $2,818.38 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,454.71 / $4,365.16
| Professional | | $1,778.28 | $2,454.71 | $4,365.16 |