- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,897.79 / $4,897.79
| Facility | | $1,380.38 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,737.80 / $3,019.95
| Professional | | $1,148.15 | $1,737.80 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $10,000.00 / $13,182.57
| Facility | | $2,398.83 | $10,000.00 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $3,715.35
| Professional | | $2,041.74 | $2,398.83 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $21,877.62 / $43,651.58
| Facility | | $1,348.96 | $21,877.62 | $43,651.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $7,079.46 / $8,511.38
| Professional | | $3,162.28 | $7,079.46 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $6,025.60 / $10,715.19
| Facility | | $2,691.53 | $6,025.60 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,187.76 / $3,548.13
| Professional | | $1,698.24 | $2,187.76 | $3,548.13 |