- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,570.88 / $11,220.18
| Facility | | $1,513.56 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,621.81 / $3,467.37
| Professional | | $1,318.26 | $1,621.81 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $10,000.00 / $20,892.96
| Facility | | $3,630.78 | $10,000.00 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,995.26 / $3,630.78
| Professional | | $1,348.96 | $1,995.26 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $3,467.37 / $9,549.93
| Facility | | $398.11 | $3,467.37 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,238.72 / $4,570.88
| Professional | | $1,412.54 | $2,238.72 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,162.28 / $10,232.93
| Facility | | $851.14 | $3,162.28 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,819.70 / $3,311.31
| Professional | | $1,288.25 | $1,819.70 | $3,311.31 |