- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,819.70 / $10,964.78
| Facility | | $870.96 | $1,819.70 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,908.68 / $22,908.68 / $22,908.68
| Professional | | $22,908.68 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $10,000.00
| Facility | | $9,120.11 | $9,120.11 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Professional | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $7,943.28
| Facility | | $7,943.28 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $6,025.60 / $15,848.93
| Facility | | $1,174.90 | $6,025.60 | $15,848.93 |