- 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
- $3,890.45 / $4,897.79 / $10,715.19
| Professional | | $3,890.45 | $4,897.79 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $13,803.84 / $28,183.83
| Facility | | $4,897.79 | $13,803.84 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,025.60 / $11,481.54
| Professional | | $4,073.80 | $6,025.60 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $10,000.00 / $29,512.09
| Facility | | $398.11 | $10,000.00 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,918.31 / $14,791.08
| Professional | | $4,365.16 | $6,918.31 | $14,791.08 |
- 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
- $4,073.80 / $5,754.40 / $10,964.78
| Professional | | $4,073.80 | $5,754.40 | $10,964.78 |