- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,317.64 / $16,218.10
| Facility | | $4,570.88 | $8,317.64 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,778.28 / $3,890.45
| Professional | | $1,380.38 | $1,778.28 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $12,302.69 / $13,803.84
| Facility | | $7,413.10 | $12,302.69 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,884.03 / $3,801.89
| Professional | | $1,348.96 | $2,884.03 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,238.72 / $4,677.35
| Professional | | $1,258.93 | $2,238.72 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,698.24 / $2,511.89
| Professional | | $1,000.00 | $1,698.24 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $8,709.64 / $11,748.98
| Facility | | $5,754.40 | $8,709.64 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,778.28 / $4,365.16
| Professional | | $1,348.96 | $1,778.28 | $4,365.16 |