- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $5,888.44 / $14,454.40
| Facility | | $1,445.44 | $5,888.44 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,096.48 / $2,398.83
| Professional | | $912.01 | $1,096.48 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $10,000.00 / $20,417.38
| Facility | | $3,801.89 | $10,000.00 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,288.25 / $2,454.71
| Professional | | $851.14 | $1,288.25 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,467.37 / $16,595.87
| Facility | | $1,000.00 | $3,467.37 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,479.11 / $3,162.28
| Professional | | $933.25 | $1,479.11 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $8,709.64 / $18,620.87
| Facility | | $3,019.95 | $8,709.64 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,230.27 / $2,238.72
| Professional | | $851.14 | $1,230.27 | $2,238.72 |