- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,466.84 / $8,511.38
| Facility | | $4,168.69 | $4,466.84 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,466.84 / $6,456.54
| Professional | | $3,890.45 | $4,466.84 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $10,000.00 / $12,022.64
| Professional | | $8,128.31 | $10,000.00 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $7,943.28 / $13,803.84
| Professional | | $5,888.44 | $7,943.28 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,309.57 / $13,182.57
| Facility | | $4,466.84 | $6,309.57 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $7,943.28 / $9,549.93
| Professional | | $4,073.80 | $7,943.28 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $7,943.28 / $10,715.19
| Professional | | $4,073.80 | $7,943.28 | $10,715.19 |