- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $9,120.11 / $16,595.87
| Facility | | $6,760.83 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,187.76 / $2,511.89
| Professional | | $1,000.00 | $2,187.76 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,022.64 / $21,379.62 / $38,018.94
| Facility | | $12,022.64 | $21,379.62 | $38,018.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,691.53 / $7,585.78
| Facility | | $1,479.11 | $2,691.53 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $22,387.21 / $37,153.52
| Facility | | $8,317.64 | $22,387.21 | $37,153.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $3,801.89
| Professional | | $1,148.15 | $1,621.81 | $3,801.89 |