- 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
- $1,778.28 / $2,089.30 / $4,786.30
| Professional | | $1,778.28 | $2,089.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $10,000.00 / $20,892.96
| Facility | | $3,630.78 | $10,000.00 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,630.27 / $5,011.87
| Professional | | $1,778.28 | $2,630.27 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $4,786.30 / $13,489.63
| Facility | | $398.11 | $4,786.30 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,090.30 / $6,606.93
| Professional | | $1,905.46 | $3,090.30 | $6,606.93 |
- 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
- $1,737.80 / $2,511.89 / $4,786.30
| Professional | | $1,737.80 | $2,511.89 | $4,786.30 |