- 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
- $1,905.46 / $2,570.40 / $6,025.60
| Professional | | $1,905.46 | $2,570.40 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,760.83 / $8,709.64
| Professional | | $5,011.87 | $6,760.83 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,019.95 / $13,803.84
| Facility | | $1,737.80 | $3,019.95 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,760.83 / $10,232.93
| Professional | | $4,466.84 | $6,760.83 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $8,317.64 / $11,748.98
| Professional | | $6,456.54 | $8,317.64 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,951.21 / $10,964.78
| Facility | | $1,905.46 | $2,951.21 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $2,818.38 / $6,760.83
| Professional | | $60.26 | $2,818.38 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $9,332.54 / $12,022.64
| Professional | | $2,187.76 | $9,332.54 | $12,022.64 |