- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,715.35 / $11,220.18
| Facility | | $2,818.38 | $3,715.35 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,951.21 / $4,677.35
| Professional | | $2,187.76 | $2,951.21 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,454.71 / $10,000.00
| Facility | | $1,905.46 | $2,454.71 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,570.88 / $5,495.41
| Professional | | $1,380.38 | $4,570.88 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,715.35 / $6,456.54
| Facility | | $2,754.23 | $3,715.35 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $5,623.41
| Professional | | $1,230.27 | $1,584.89 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,715.35 / $4,466.84
| Facility | | $1,584.89 | $3,715.35 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $2,454.71
| Professional | | $1,230.27 | $1,584.89 | $2,454.71 |