- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,845.36 / $10,900.00 / $14,552.94
| Facility | | $3,845.36 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,697.50 / $7,385.81 / $7,385.81
| Professional | | $6,697.50 | $7,385.81 | $7,385.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,537.34 / $4,537.34 / $4,537.34
| Professional | | $4,537.34 | $4,537.34 | $4,537.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,618.62 / $7,385.81 / $10,561.71
| Facility | | $1,618.62 | $7,385.81 | $10,561.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,157.03 / $6,832.00 / $10,621.13
| Professional | | $3,157.03 | $6,832.00 | $10,621.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,880.00 / $5,660.80 / $8,498.53
| Professional | | $4,880.00 | $5,660.80 | $8,498.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,618.62 / $7,385.81 / $10,561.71
| Facility | | $1,618.62 | $7,385.81 | $10,561.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.16 / $5,788.50 / $8,862.75
| Professional | | $1,267.16 | $5,788.50 | $8,862.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,629.88 / $5,444.82 / $8,389.76
| Professional | | $3,629.88 | $5,444.82 | $8,389.76 |