- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,288.25 / $8,511.38
| Facility | | $1,230.27 | $1,288.25 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,288.25 / $3,162.28
| Professional | | $1,071.52 | $1,288.25 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,818.38 / $3,388.44
| Professional | | $2,290.87 | $2,818.38 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,398.83 / $3,981.07
| Professional | | $1,412.54 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,584.89 / $3,890.45
| Facility | | $1,288.25 | $1,584.89 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,344.23 / $10,000.00
| Professional | | $1,230.27 | $2,344.23 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,888.44 / $16,982.44
| Facility | | $5,370.32 | $5,888.44 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,344.23 / $3,162.28
| Professional | | $1,230.27 | $2,344.23 | $3,162.28 |