- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,724.00 / $10,915.56 / $21,899.37
| Facility | | $5,724.00 | $10,915.56 | $21,899.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.00 / $1,736.36 / $16,536.72
| Professional | | $1,295.00 | $1,736.36 | $16,536.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,828.40 / $10,296.48 / $19,916.72
| Facility | | $7,828.40 | $10,296.48 | $19,916.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,291.18 / $14,291.18 / $14,291.18
| Facility | | $14,291.18 | $14,291.18 | $14,291.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $9,696.00 / $33,073.44
| Facility | | $100.00 | $9,696.00 | $33,073.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,725.73 / $14,291.18 / $19,054.90
| Facility | | $10,725.73 | $14,291.18 | $19,054.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,777.00 / $8,220.00 / $9,696.00
| Facility | | $6,777.00 | $8,220.00 | $9,696.00 |