- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $6,025.60 / $33,113.11
| Facility | | $3,388.44 | $6,025.60 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,380.38 / $3,388.44
| Professional | | $1,202.26 | $1,380.38 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,380.38 / $2,454.71
| Professional | | $1,000.00 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $10,715.19
| Facility | | $10,715.19 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,511.89
| Facility | | $1,995.26 | $1,995.26 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,412.54 / $2,290.87
| Professional | | $1,122.02 | $1,412.54 | $2,290.87 |