- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,570.88 / $11,481.54
| Facility | | $1,584.89 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,698.24 / $3,467.37
| Professional | | $1,380.38 | $1,698.24 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $10,964.78 / $20,892.96
| Facility | | $3,890.45 | $10,964.78 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,949.84 / $3,801.89
| Professional | | $1,348.96 | $1,949.84 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $3,801.89 / $10,000.00
| Facility | | $398.11 | $3,801.89 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,344.23 / $4,786.30
| Professional | | $1,445.44 | $2,344.23 | $4,786.30 |
- 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
- $1,318.26 / $1,905.46 / $3,467.37
| Professional | | $1,318.26 | $1,905.46 | $3,467.37 |