- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,630.78 / $8,128.31
| Facility | | $1,621.81 | $3,630.78 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,288.25 / $2,290.87
| Professional | | $1,122.02 | $1,288.25 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,801.89 / $3,801.89
| Facility | | $3,548.13 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $1,819.70
| Professional | | $1,819.70 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Facility | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,737.80 / $2,570.40
| Professional | | $1,318.26 | $1,737.80 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,995.26 / $11,748.98
| Facility | | $1,288.25 | $1,995.26 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,621.81 / $10,000.00
| Professional | | $1,288.25 | $1,621.81 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,786.30 / $9,772.37
| Facility | | $1,995.26 | $4,786.30 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $2,137.96
| Professional | | $1,258.93 | $1,548.82 | $2,137.96 |