- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,309.57 / $9,772.37
| Facility | | $2,398.83 | $6,309.57 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,786.30 / $6,309.57
| Professional | | $1,819.70 | $4,786.30 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $10,000.00 / $18,197.01
| Facility | | $8,912.51 | $10,000.00 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $8,912.51 / $12,882.50
| Professional | | $3,890.45 | $8,912.51 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,165.95 / $9,772.37 / $12,022.64
| Professional | | $6,165.95 | $9,772.37 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,762.47 / $12,022.64
| Professional | | $4,365.16 | $7,762.47 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $7,762.47 / $15,135.61
| Professional | | $2,187.76 | $7,762.47 | $15,135.61 |