- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,137.96 / $7,762.47
| Facility | | $1,445.44 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,445.44 / $3,311.31
| Professional | | $1,258.93 | $1,445.44 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,513.56 / $1,819.70
| Professional | | $1,230.27 | $1,513.56 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $3,630.78
| Professional | | $1,288.25 | $1,698.24 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,884.03 / $3,235.94
| Professional | | $1,445.44 | $2,884.03 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $10,000.00 / $47,863.01
| Facility | | $7,244.36 | $10,000.00 | $47,863.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,819.70 / $3,801.89
| Professional | | $1,000.00 | $1,819.70 | $3,801.89 |