- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,025.60 / $9,772.37
| Facility | | $2,398.83 | $6,025.60 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,737.80 / $4,677.35
| Professional | | $1,000.00 | $1,737.80 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,772.37 / $15,135.61
| Facility | | $5,495.41 | $9,772.37 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,162.28 / $4,466.84
| Professional | | $1,348.96 | $3,162.28 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,467.37 / $4,265.80
| Professional | | $2,187.76 | $3,467.37 | $4,265.80 |
- 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
- $1,584.89 / $2,754.23 / $4,168.69
| Professional | | $1,584.89 | $2,754.23 | $4,168.69 |
- 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
- $1,995.26 / $2,754.23 / $5,248.07
| Professional | | $1,995.26 | $2,754.23 | $5,248.07 |