- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,623.41 / $10,000.00
| Facility | | $2,754.23 | $5,623.41 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $2,238.72 / $6,760.83
| Professional | | $169.82 | $2,238.72 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,677.35 / $8,912.51
| Facility | | $2,238.72 | $4,677.35 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $10,715.19 / $22,908.68
| Facility | | $2,511.89 | $10,715.19 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Professional | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,495.41 / $11,220.18
| Facility | | $2,570.40 | $5,495.41 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Professional | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,890.45 / $6,165.95
| Facility | | $2,454.71 | $3,890.45 | $6,165.95 |