- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,890.45 / $15,848.93
| Facility | | $2,398.83 | $3,890.45 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,380.38 / $1,380.38
| Professional | | $870.96 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $10,000.00 / $18,197.01
| Facility | | $8,912.51 | $10,000.00 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $1,584.89
| Professional | | $1,584.89 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Professional | | $6,456.54 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $12,302.69 / $12,302.69
| Facility | | $12,302.69 | $12,302.69 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,187.76 / $3,388.44
| Professional | | $1,513.56 | $2,187.76 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $12,302.69 / $12,302.69
| Facility | | $12,302.69 | $12,302.69 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,137.96 / $3,890.45
| Professional | | $1,445.44 | $2,137.96 | $3,890.45 |