- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,786.30 / $8,511.38
| Facility | | $4,265.80 | $4,786.30 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,370.32 / $10,000.00
| Professional | | $4,265.80 | $5,370.32 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,912.51 / $10,471.29 / $12,589.25
| Professional | | $8,912.51 | $10,471.29 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $8,511.38 / $13,182.57
| Professional | | $4,365.16 | $8,511.38 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,606.93 / $11,481.54
| Facility | | $4,073.80 | $6,606.93 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $8,128.31 / $35,481.34
| Professional | | $4,265.80 | $8,128.31 | $35,481.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,819.70 / $2,041.74
| Facility | | $676.08 | $1,819.70 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,760.83 / $10,471.29
| Professional | | $4,265.80 | $6,760.83 | $10,471.29 |