- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $10,000.00 / $28,840.32
| Facility | | $4,466.84 | $10,000.00 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,949.84 / $3,715.35
| Professional | | $1,621.81 | $1,949.84 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $12,882.50 / $67,608.30
| Facility | | $3,090.30 | $12,882.50 | $67,608.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,187.76 / $4,466.84
| Professional | | $1,380.38 | $2,187.76 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,187.76 / $3,467.37
| Professional | | $1,862.09 | $2,187.76 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $223.87
| Facility | | $109.65 | $109.65 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,089.30 / $4,265.80
| Professional | | $1,445.44 | $2,089.30 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,248.07 / $10,471.29
| Facility | | $1,513.56 | $5,248.07 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,862.09 / $3,715.35
| Professional | | $1,202.26 | $1,862.09 | $3,715.35 |