- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,265.80 / $8,317.64
| Facility | | $1,230.27 | $4,265.80 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,348.96 / $1,698.24
| Professional | | $1,230.27 | $1,348.96 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,862.09 / $2,454.71
| Professional | | $1,737.80 | $1,862.09 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,265.80 / $10,000.00
| Facility | | $1,122.02 | $4,265.80 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,513.56 / $2,951.21
| Facility | | $1,318.26 | $1,513.56 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,737.80 / $2,089.30
| Facility | | $1,548.82 | $1,737.80 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,047.13 / $1,737.80
| Professional | | $724.44 | $1,047.13 | $1,737.80 |