- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,265.80 / $9,549.93
| Facility | | $2,344.23 | $4,265.80 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,890.45 / $15,488.17
| Professional | | $2,344.23 | $3,890.45 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,090.30 / $11,220.18
| Facility | | $891.25 | $3,090.30 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $426.58 / $3,090.30
| Professional | | $380.19 | $426.58 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,466.84 / $10,000.00
| Facility | | $1,513.56 | $4,466.84 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,818.38 / $5,754.40
| Professional | | $1,174.90 | $2,818.38 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,344.23 / $2,818.38
| Facility | | $1,412.54 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,412.54 / $2,818.38
| Professional | | $977.24 | $1,412.54 | $2,818.38 |