- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,128.61 / $11,481.54
| Facility | | $1,862.09 | $5,128.61 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,630.78 / $7,244.36
| Professional | | $2,951.21 | $3,630.78 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $11,748.98 / $27,542.29
| Facility | | $4,466.84 | $11,748.98 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,073.80 / $7,943.28
| Professional | | $2,630.27 | $4,073.80 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $8,912.51 / $24,547.09
| Facility | | $323.59 | $8,912.51 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,897.79 / $10,000.00
| Professional | | $2,951.21 | $4,897.79 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,162.28 / $10,232.93
| Facility | | $851.14 | $3,162.28 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,981.07 / $7,413.10
| Professional | | $2,691.53 | $3,981.07 | $7,413.10 |