- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $10,000.00 / $17,782.79
| Facility | | $3,981.07 | $10,000.00 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,311.31 / $7,943.28
| Facility | | $2,398.83 | $3,311.31 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,398.83 / $3,801.89
| Professional | | $1,862.09 | $2,398.83 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $2,041.74 / $6,456.54
| Facility | | $776.25 | $2,041.74 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,047.13 / $1,659.59
| Professional | | $776.25 | $1,047.13 | $1,659.59 |