- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $9,772.37 / $14,791.08
| Facility | | $2,398.83 | $9,772.37 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,467.37 / $6,760.83
| Professional | | $2,951.21 | $3,467.37 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,677.35 / $6,309.57
| Facility | | $3,467.37 | $4,677.35 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,309.57 / $8,709.64
| Professional | | $2,951.21 | $6,309.57 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,495.41 / $10,000.00
| Professional | | $3,890.45 | $5,495.41 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,128.61 / $7,762.47
| Professional | | $3,467.37 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,897.79 / $8,912.51
| Professional | | $3,467.37 | $4,897.79 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,981.07
| Facility | | $2,454.71 | $2,454.71 | $3,981.07 |