- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $5,248.07 / $12,882.50
| Facility | | $1,096.48 | $5,248.07 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $1,621.81
| Professional | | $549.54 | $660.69 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $11,220.18 / $23,988.33
| Facility | | $3,890.45 | $11,220.18 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $851.14 / $1,584.89
| Professional | | $575.44 | $851.14 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,511.89 / $10,000.00
| Facility | | $1,202.26 | $2,511.89 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $933.25 / $2,137.96
| Professional | | $602.56 | $933.25 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $7,244.36 / $16,982.44
| Facility | | $2,454.71 | $7,244.36 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $741.31 / $1,380.38
| Professional | | $512.86 | $741.31 | $1,380.38 |