- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,456.54 / $9,772.37
| Facility | | $2,398.83 | $6,456.54 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,548.82 / $5,011.87
| Professional | | $1,412.54 | $1,548.82 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $19,952.62 / $31,622.78
| Facility | | $10,000.00 | $19,952.62 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,090.30 / $4,466.84
| Professional | | $1,548.82 | $3,090.30 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $3,715.35 / $5,495.41
| Professional | | $389.05 | $3,715.35 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,818.38 / $4,897.79
| Professional | | $1,778.28 | $2,818.38 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,019.95 / $4,897.79
| Professional | | $1,862.09 | $3,019.95 | $4,897.79 |