- 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
- $2,570.40 / $3,715.35 / $4,466.84
| Professional | | $2,570.40 | $3,715.35 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,466.84 / $6,606.93
| Facility | | $3,630.78 | $4,466.84 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,890.45 / $4,786.30
| Professional | | $2,511.89 | $3,890.45 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,466.84 / $6,606.93
| Facility | | $3,467.37 | $4,466.84 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $6,456.54
| Professional | | $1,258.93 | $1,258.93 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $8,128.31 / $13,803.84
| Professional | | $3,548.13 | $8,128.31 | $13,803.84 |