- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,344.23 / $4,073.80
| Facility | | $1,819.70 | $2,344.23 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,398.83 / $3,890.45
| Professional | | $1,819.70 | $2,398.83 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,570.40 / $10,000.00
| Facility | | $1,905.46 | $2,570.40 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,630.27 / $5,370.32
| Professional | | $2,398.83 | $2,630.27 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $17,378.01
| Facility | | $3,019.95 | $3,019.95 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $6,760.83
| Professional | | $2,187.76 | $2,187.76 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,162.28 / $5,623.41
| Facility | | $2,570.40 | $3,162.28 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,290.87 / $3,548.13
| Professional | | $1,698.24 | $2,290.87 | $3,548.13 |