- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,897.79 / $10,471.29
| Facility | | $3,019.95 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,737.80 / $4,570.88
| Professional | | $1,412.54 | $1,737.80 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $21,877.62 / $26,915.35
| Facility | | $8,912.51 | $21,877.62 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,235.94 / $4,677.35
| Professional | | $1,949.84 | $3,235.94 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $15,488.17 / $33,884.42
| Facility | | $2,187.76 | $15,488.17 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,884.03 / $4,570.88
| Professional | | $1,819.70 | $2,884.03 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,238.72 / $3,467.37
| Professional | | $1,621.81 | $2,238.72 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,754.40 / $10,000.00
| Facility | | $1,513.56 | $5,754.40 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,238.72 / $4,786.30
| Professional | | $1,348.96 | $2,238.72 | $4,786.30 |