- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,365.16 / $8,317.64
| Facility | | $1,230.27 | $4,365.16 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,412.54 / $1,949.84
| Professional | | $1,230.27 | $1,412.54 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,862.09 / $2,454.71
| Professional | | $1,737.80 | $1,862.09 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,365.16 / $10,000.00
| Facility | | $1,148.15 | $4,365.16 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,445.44 / $2,344.23
| Facility | | $1,148.15 | $1,445.44 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,737.80 / $2,089.30
| Facility | | $1,584.89 | $1,737.80 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $1,737.80
| Professional | | $741.31 | $1,047.13 | $1,737.80 |