- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,570.88 / $11,481.54
| Facility | | $1,479.11 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,621.81 / $3,162.28
| Professional | | $1,288.25 | $1,621.81 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $10,000.00 / $18,620.87
| Facility | | $3,630.78 | $10,000.00 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,819.70 / $3,548.13
| Professional | | $1,202.26 | $1,819.70 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $3,801.89 / $10,471.29
| Facility | | $323.59 | $3,801.89 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,238.72 / $4,265.80
| Professional | | $1,380.38 | $2,238.72 | $4,265.80 |
- 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
- $1,258.93 / $1,819.70 / $3,311.31
| Professional | | $1,258.93 | $1,819.70 | $3,311.31 |