- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $10,000.00 / $25,703.96
| Facility | | $3,890.45 | $10,000.00 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,073.80 / $6,025.60
| Professional | | $3,090.30 | $4,073.80 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $6,760.83 / $10,232.93
| Facility | | $2,089.30 | $6,760.83 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,365.16 / $8,317.64
| Professional | | $4,168.69 | $4,365.16 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,890.45 / $14,125.38
| Facility | | $2,884.03 | $3,890.45 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,011.87 / $9,120.11
| Facility | | $3,388.44 | $5,011.87 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $25,118.86
| Professional | | $2,089.30 | $2,089.30 | $25,118.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,011.87 / $6,025.60
| Facility | | $4,466.84 | $5,011.87 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $3,019.95
| Professional | | $2,089.30 | $2,089.30 | $3,019.95 |