- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,025.60 / $9,549.93
| Facility | | $4,570.88 | $6,025.60 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,888.44 / $7,943.28
| Professional | | $4,073.80 | $5,888.44 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $588.84 / $18,620.87
| Facility | | $588.84 | $588.84 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,762.47 / $10,232.93
| Professional | | $5,495.41 | $7,762.47 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $10,000.00
| Facility | | $4,897.79 | $4,897.79 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,897.79 / $14,454.40
| Professional | | $4,168.69 | $4,897.79 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $3,801.89 / $7,413.10
| Facility | | $457.09 | $3,801.89 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,128.61 / $8,709.64
| Professional | | $3,630.78 | $5,128.61 | $8,709.64 |