- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,677.35 / $12,022.64
| Facility | | $1,479.11 | $4,677.35 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,584.89 / $3,162.28
| Professional | | $1,258.93 | $1,584.89 | $3,162.28 |
- 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 / $3,388.44 / $10,000.00
| Facility | | $398.11 | $3,388.44 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,187.76 / $4,365.16
| Professional | | $1,348.96 | $2,187.76 | $4,365.16 |
- 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 / $3,235.94
| Professional | | $1,230.27 | $1,778.28 | $3,235.94 |