- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,888.44 / $9,772.37
| Facility | | $2,398.83 | $5,888.44 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,949.84 / $4,570.88
| Professional | | $1,122.02 | $1,949.84 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $10,000.00 / $18,197.01
| Facility | | $8,912.51 | $10,000.00 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,715.35 / $5,370.32
| Professional | | $1,621.81 | $3,715.35 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,073.80 / $5,011.87
| Professional | | $2,570.40 | $4,073.80 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,311.31 / $5,128.61
| Professional | | $1,862.09 | $3,311.31 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,235.94 / $6,309.57
| Professional | | $2,187.76 | $3,235.94 | $6,309.57 |