- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $5,011.87 / $12,589.25
| Facility | | $1,584.89 | $5,011.87 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,659.59 / $4,677.35
| Professional | | $1,288.25 | $1,659.59 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $10,000.00 / $18,620.87
| Facility | | $3,388.44 | $10,000.00 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,862.09 / $3,801.89
| Professional | | $1,288.25 | $1,862.09 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $3,715.35 / $10,471.29
| Facility | | $323.59 | $3,715.35 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,089.30 / $4,466.84
| Professional | | $1,380.38 | $2,089.30 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $7,079.46 / $16,218.10
| Facility | | $2,398.83 | $7,079.46 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,698.24 / $3,162.28
| Professional | | $1,174.90 | $1,698.24 | $3,162.28 |