- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,754.23 / $11,481.54
| Facility | | $2,398.83 | $2,754.23 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,715.35 / $17,378.01
| Professional | | $1,479.11 | $3,715.35 | $17,378.01 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $4,570.88 / $11,220.18
| Facility | | $977.24 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $4,570.88 / $11,220.18
| Facility | | $977.24 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,388.44 / $4,168.69
| Facility | | $2,511.89 | $3,388.44 | $4,168.69 |