- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,623.41 / $10,000.00
| Facility | | $2,630.27 | $5,623.41 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,041.74 / $2,630.27
| Professional | | $1,778.28 | $2,041.74 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Professional | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,897.79 / $6,165.95
| Facility | | $2,454.71 | $4,897.79 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,691.53 / $3,630.78
| Facility | | $2,187.76 | $2,691.53 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $13,489.63
| Professional | | $1,148.15 | $1,621.81 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,691.53 / $3,235.94
| Facility | | $1,148.15 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $3,548.13
| Professional | | $1,148.15 | $1,621.81 | $3,548.13 |