- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $11,220.18 / $21,379.62
| Facility | | $8,317.64 | $11,220.18 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $8,709.64 / $14,454.40
| Professional | | $1,000.00 | $8,709.64 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,782.79 / $23,988.33 / $26,915.35
| Professional | | $17,782.79 | $23,988.33 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,803.84 / $13,803.84 / $17,378.01
| Professional | | $13,803.84 | $13,803.84 | $17,378.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $9,120.11 / $21,379.62
| Facility | | $1,000.00 | $9,120.11 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $14,125.38 / $23,988.33
| Professional | | $5,011.87 | $14,125.38 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $12,022.64 / $17,378.01
| Professional | | $5,011.87 | $12,022.64 | $17,378.01 |