- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,801.89 / $10,000.00
| Facility | | $1,819.70 | $3,801.89 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,778.28 / $2,187.76
| Professional | | $1,348.96 | $1,778.28 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,715.35 / $10,715.19
| Facility | | $1,698.24 | $3,715.35 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $588.84 / $2,691.53
| Professional | | $512.86 | $588.84 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,630.78 / $9,332.54
| Facility | | $1,445.44 | $3,630.78 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,235.94 / $6,025.60
| Professional | | $2,570.40 | $3,235.94 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,187.76 / $2,630.27
| Facility | | $1,318.26 | $2,187.76 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,630.27
| Professional | | $933.25 | $1,318.26 | $2,630.27 |