- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,165.95 / $9,772.37
| Facility | | $2,398.83 | $6,165.95 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,905.46 / $4,897.79
| Professional | | $1,659.59 | $1,905.46 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $21,877.62 / $34,673.69
| Facility | | $10,000.00 | $21,877.62 | $34,673.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,715.35 / $5,370.32
| Professional | | $1,819.70 | $3,715.35 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $3,548.13 / $5,623.41
| Professional | | $870.96 | $3,548.13 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,388.44 / $5,495.41
| Professional | | $2,089.30 | $3,388.44 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,235.94 / $5,495.41
| Professional | | $2,041.74 | $3,235.94 | $5,495.41 |