- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,365.16 / $15,488.17
| Facility | | $3,235.94 | $4,365.16 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,398.83 / $3,715.35
| Professional | | $1,819.70 | $2,398.83 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $6,760.83 / $10,000.00
| Facility | | $3,548.13 | $6,760.83 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $933.25 / $933.25
| Professional | | $794.33 | $933.25 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,388.44 / $22,908.68
| Facility | | $1,949.84 | $3,388.44 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,019.95 / $3,019.95
| Facility | | $1,258.93 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $4,265.80
| Professional | | $1,258.93 | $1,513.56 | $4,265.80 |