- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,623.41 / $9,549.93
| Facility | | $4,466.84 | $5,623.41 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,623.41 / $8,912.51
| Professional | | $4,265.80 | $5,623.41 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $6,918.31 / $15,135.61
| Facility | | $2,344.23 | $6,918.31 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,456.54 / $10,000.00
| Professional | | $4,365.16 | $6,456.54 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,754.40 / $8,128.31
| Professional | | $5,495.41 | $5,754.40 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,235.94 / $8,128.31
| Facility | | $1,047.13 | $3,235.94 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,888.44 / $14,125.38
| Professional | | $4,265.80 | $5,888.44 | $14,125.38 |