- 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
- $1,584.89 / $2,238.72 / $2,754.23
| Professional | | $1,584.89 | $2,238.72 | $2,754.23 |
- 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
- $1,819.70 / $3,981.07 / $5,754.40
| Professional | | $1,819.70 | $3,981.07 | $5,754.40 |
- 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
- $2,041.74 / $3,548.13 / $6,165.95
| Professional | | $2,041.74 | $3,548.13 | $6,165.95 |