- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,511.38 / $13,489.63
| Facility | | $4,570.88 | $8,511.38 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $2,511.89
| Professional | | $1,513.56 | $2,137.96 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $17,378.01 / $26,915.35
| Facility | | $8,912.51 | $17,378.01 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,715.35 / $5,248.07
| Professional | | $1,659.59 | $3,715.35 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Facility | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,754.40 / $10,000.00
| Facility | | $1,513.56 | $5,754.40 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,467.37 / $5,888.44
| Professional | | $1,995.26 | $3,467.37 | $5,888.44 |