- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,576.89 / $10,900.00 / $14,552.94
| Facility | | $4,576.89 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,967.25 / $8,790.86 / $8,790.86
| Professional | | $7,967.25 | $8,790.86 | $8,790.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,407.80 / $5,407.80 / $5,407.80
| Professional | | $5,407.80 | $5,407.80 | $5,407.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,926.74 / $8,790.86 / $12,570.93
| Facility | | $1,926.74 | $8,790.86 | $12,570.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,752.20 / $9,744.00 / $12,641.85
| Professional | | $3,752.20 | $9,744.00 | $12,641.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,800.00 / $6,728.00 / $10,770.90
| Professional | | $5,800.00 | $6,728.00 | $10,770.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,926.74 / $8,790.86 / $12,570.93
| Facility | | $1,926.74 | $8,790.86 | $12,570.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,605.98 / $6,891.00 / $10,979.43
| Professional | | $1,605.98 | $6,891.00 | $10,979.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,326.24 / $6,489.36 / $10,398.07
| Professional | | $4,326.24 | $6,489.36 | $10,398.07 |