- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $8,709.64 / $10,232.93
| Facility | | $2,398.83 | $8,709.64 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,000.00 / $2,884.03
| Professional | | $851.14 | $1,000.00 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,000.00 / $1,621.81
| Professional | | $851.14 | $1,000.00 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,479.11 / $2,041.74
| Professional | | $1,122.02 | $1,479.11 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $10,000.00
| Facility | | $2,818.38 | $5,128.61 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,174.90 / $2,187.76
| Professional | | $831.76 | $1,174.90 | $2,187.76 |