- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,332.54 / $13,803.84
| Facility | | $4,570.88 | $9,332.54 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,621.81 / $5,370.32
| Professional | | $1,348.96 | $1,621.81 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,089.30 / $5,128.61
| Professional | | $1,445.44 | $2,089.30 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,230.27 / $2,041.74
| Professional | | $1,122.02 | $1,230.27 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,471.29 / $16,595.87
| Facility | | $6,606.93 | $10,471.29 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,137.96 / $6,309.57
| Professional | | $1,445.44 | $2,137.96 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,709.64 / $21,379.62
| Facility | | $4,570.88 | $8,709.64 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,479.11 / $3,311.31
| Professional | | $1,000.00 | $1,479.11 | $3,311.31 |