- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,677.35 / $11,481.54
| Facility | | $1,819.70 | $4,677.35 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,570.40 / $5,128.61
| Professional | | $2,089.30 | $2,570.40 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $10,000.00 / $18,197.01
| Facility | | $3,981.07 | $10,000.00 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,090.30 / $6,165.95
| Professional | | $2,041.74 | $3,090.30 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $5,495.41 / $14,125.38
| Facility | | $398.11 | $5,495.41 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,548.13 / $7,079.46
| Professional | | $2,238.72 | $3,548.13 | $7,079.46 |
- 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
- $2,041.74 / $2,951.21 / $5,370.32
| Professional | | $2,041.74 | $2,951.21 | $5,370.32 |