- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,918.31 / $11,481.54
| Facility | | $4,570.88 | $6,918.31 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,918.31 / $13,803.84
| Professional | | $4,570.88 | $6,918.31 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,754.40 / $17,378.01
| Facility | | $2,089.30 | $5,754.40 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,174.90 / $1,174.90
| Professional | | $1,000.00 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $12,589.25 / $18,197.01
| Facility | | $6,025.60 | $12,589.25 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,235.94 / $8,128.31
| Facility | | $1,047.13 | $3,235.94 | $8,128.31 |