- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $5,128.61 / $10,000.00
| Facility | | $1,584.89 | $5,128.61 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,258.93 / $1,513.56
| Professional | | $1,071.52 | $1,258.93 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $11,481.54 / $23,988.33
| Facility | | $6,025.60 | $11,481.54 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $107.15 / $147.91
| Professional | | $77.62 | $107.15 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $1,513.56 / $1,513.56
| Professional | | $338.84 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,754.40 / $12,302.69
| Facility | | $2,630.27 | $5,754.40 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,187.76 / $3,630.78
| Professional | | $1,621.81 | $2,187.76 | $3,630.78 |