- 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 / $3,311.31
| Professional | | $1,318.26 | $1,621.81 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $13,489.63 / $28,840.32
| Facility | | $4,677.35 | $13,489.63 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,862.09 / $3,630.78
| Professional | | $1,230.27 | $1,862.09 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $3,467.37 / $10,000.00
| Facility | | $398.11 | $3,467.37 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,187.76 / $4,570.88
| Professional | | $1,348.96 | $2,187.76 | $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
- $1,230.27 / $1,778.28 / $3,311.31
| Professional | | $1,230.27 | $1,778.28 | $3,311.31 |