- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $5,370.32 / $11,481.54
| Facility | | $1,819.70 | $5,370.32 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,897.79 / $8,912.51
| Professional | | $2,754.23 | $4,897.79 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $14,791.08 / $28,840.32
| Facility | | $4,365.16 | $14,791.08 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,168.69 / $9,772.37
| Professional | | $1,995.26 | $4,168.69 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $10,000.00 / $27,542.29
| Facility | | $398.11 | $10,000.00 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $6,456.54 / $13,489.63
| Professional | | $2,187.76 | $6,456.54 | $13,489.63 |
- 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
- $1,819.70 / $4,677.35 / $10,000.00
| Professional | | $1,819.70 | $4,677.35 | $10,000.00 |