- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $10,000.00 / $15,135.61
| Facility | | $2,187.76 | $10,000.00 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,511.89 / $3,467.37
| Professional | | $2,187.76 | $2,511.89 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,388.44 / $4,466.84
| Professional | | $3,162.28 | $3,388.44 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $7,762.47 / $18,197.01
| Facility | | $2,041.74 | $7,762.47 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,570.40 / $3,981.07
| Facility | | $1,905.46 | $2,570.40 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,162.28 / $3,801.89
| Facility | | $2,818.38 | $3,162.28 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $3,162.28
| Professional | | $1,318.26 | $1,905.46 | $3,162.28 |