- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $10,000.00 / $19,952.62
| Facility | | $2,570.40 | $10,000.00 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,754.23 / $3,467.37
| Professional | | $2,187.76 | $2,754.23 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $14,791.08
| Facility | | $1,995.26 | $2,691.53 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,466.84 / $17,782.79
| Professional | | $2,951.21 | $4,466.84 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $3,090.30
| Professional | | $2,187.76 | $2,187.76 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,187.76 / $3,311.31
| Professional | | $1,513.56 | $2,187.76 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,311.31 / $3,715.35
| Facility | | $1,548.82 | $3,311.31 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,548.82 / $5,495.41
| Professional | | $1,288.25 | $1,548.82 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,187.76 / $2,187.76
| Professional | | $1,000.00 | $2,187.76 | $2,187.76 |