- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,890.45 / $7,079.46
| Facility | | $2,818.38 | $3,890.45 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,801.89 / $5,754.40
| Professional | | $2,818.38 | $3,801.89 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,073.80 / $14,125.38
| Facility | | $2,951.21 | $4,073.80 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,981.07 / $8,511.38
| Professional | | $3,388.44 | $3,981.07 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $28,183.83
| Facility | | $4,466.84 | $4,466.84 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $10,000.00
| Professional | | $3,235.94 | $3,235.94 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,011.87 / $8,912.51
| Facility | | $3,235.94 | $5,011.87 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,630.78 / $5,495.41
| Professional | | $2,511.89 | $3,630.78 | $5,495.41 |