- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,011.87 / $12,022.64
| Facility | | $1,737.80 | $5,011.87 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,737.80 / $4,265.80
| Professional | | $1,513.56 | $1,737.80 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $10,000.00 / $18,620.87
| Facility | | $3,630.78 | $10,000.00 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,137.96 / $4,570.88
| Professional | | $1,479.11 | $2,137.96 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $3,467.37 / $12,302.69
| Facility | | $398.11 | $3,467.37 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,454.71 / $5,370.32
| Professional | | $1,584.89 | $2,454.71 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $7,244.36 / $16,595.87
| Facility | | $2,344.23 | $7,244.36 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,949.84 / $3,715.35
| Professional | | $1,412.54 | $1,949.84 | $3,715.35 |