- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $12,022.64 / $16,595.87
| Facility | | $9,772.37 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,137.96 / $3,019.95
| Professional | | $1,778.28 | $2,137.96 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,290.87 / $3,630.78
| Facility | | $1,148.15 | $2,290.87 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,137.96 / $3,019.95
| Professional | | $1,000.00 | $2,137.96 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $7,413.10 / $10,715.19
| Professional | | $5,128.61 | $7,413.10 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,818.38 / $3,630.78
| Facility | | $2,290.87 | $2,818.38 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,011.87 / $11,481.54
| Professional | | $2,951.21 | $5,011.87 | $11,481.54 |