- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,897.79 / $10,471.29
| Facility | | $3,162.28 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,819.70 / $4,786.30
| Professional | | $1,445.44 | $1,819.70 | $4,786.30 |
- 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
- $1,548.82 / $3,090.30 / $4,365.16
| Professional | | $1,548.82 | $3,090.30 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Facility | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,884.03 / $4,786.30
| Professional | | $1,905.46 | $2,884.03 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,290.87 / $3,630.78
| Professional | | $1,737.80 | $2,290.87 | $3,630.78 |
- 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
- $1,380.38 / $2,290.87 / $5,011.87
| Professional | | $1,380.38 | $2,290.87 | $5,011.87 |