- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $4,365.16
| Facility | | $1,905.46 | $1,905.46 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,041.74 / $7,943.28
| Professional | | $1,202.26 | $2,041.74 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,511.89 / $3,019.95
| Professional | | $1,995.26 | $2,511.89 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,630.78 / $10,000.00
| Facility | | $1,995.26 | $3,630.78 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,570.40 / $44,668.36
| Professional | | $1,202.26 | $2,570.40 | $44,668.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $3,019.95
| Professional | | $2,511.89 | $2,511.89 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,548.13 / $10,471.29
| Professional | | $1,202.26 | $3,548.13 | $10,471.29 |