- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,495.41 / $11,748.98
| Facility | | $1,862.09 | $5,495.41 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,011.87 / $9,549.93
| Professional | | $4,168.69 | $5,011.87 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $9,549.93 / $17,782.79
| Facility | | $3,548.13 | $9,549.93 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,370.32 / $10,000.00
| Professional | | $4,073.80 | $5,370.32 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $7,943.28 / $18,620.87
| Facility | | $426.58 | $7,943.28 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,309.57 / $12,882.50
| Professional | | $3,890.45 | $6,309.57 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $2,818.38 / $9,772.37
| Facility | | $537.03 | $2,818.38 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,370.32 / $9,772.37
| Professional | | $3,890.45 | $5,370.32 | $9,772.37 |