- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,818.38 / $6,165.95
| Facility | | $1,258.93 | $2,818.38 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $1,995.26 / $6,760.83
| Professional | | $269.15 | $1,995.26 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $6,606.93 / $9,772.37
| Facility | | $2,570.40 | $6,606.93 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $512.86 / $794.33
| Facility | | $501.19 | $512.86 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Professional | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,715.35 / $10,232.93
| Facility | | $2,818.38 | $3,715.35 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,630.78 / $3,630.78
| Professional | | $2,754.23 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,623.41 / $10,000.00
| Facility | | $2,187.76 | $5,623.41 | $10,000.00 |