- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,888.44 / $15,135.61
| Facility | | $2,570.40 | $5,888.44 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,235.94 / $9,332.54
| Professional | | $1,737.80 | $3,235.94 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $11,220.18 / $12,302.69
| Facility | | $9,772.37 | $11,220.18 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $15,848.93 / $18,197.01
| Professional | | $5,623.41 | $15,848.93 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,000.00 / $16,218.10
| Facility | | $7,413.10 | $10,000.00 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,000.00 / $16,218.10
| Professional | | $7,413.10 | $10,000.00 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $11,481.54 / $23,988.33
| Facility | | $6,760.83 | $11,481.54 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $707.95
| Professional | | $707.95 | $707.95 | $707.95 |