- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,890.45 / $10,000.00
| Facility | | $1,905.46 | $3,890.45 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,737.80 / $2,344.23
| Professional | | $1,445.44 | $1,737.80 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,715.35 / $10,715.19
| Facility | | $2,238.72 | $3,715.35 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,548.82 / $3,090.30
| Professional | | $1,445.44 | $1,548.82 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,630.78 / $9,549.93
| Facility | | $1,445.44 | $3,630.78 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,235.94 / $5,370.32
| Professional | | $2,570.40 | $3,235.94 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,238.72 / $2,691.53
| Facility | | $1,000.00 | $2,238.72 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,570.40
| Professional | | $933.25 | $1,318.26 | $2,570.40 |