- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $10,000.00 / $16,982.44
| Facility | | $2,344.23 | $10,000.00 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,862.09 / $2,238.72
| Professional | | $1,513.56 | $1,862.09 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,238.72 / $3,162.28
| Facility | | $1,288.25 | $2,238.72 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,041.74 / $4,677.35
| Professional | | $977.24 | $2,041.74 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $16,218.10
| Professional | | $6,456.54 | $6,456.54 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,238.72 / $3,162.28
| Facility | | $1,288.25 | $2,238.72 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,786.30 / $10,964.78
| Professional | | $2,818.38 | $4,786.30 | $10,964.78 |