- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $4,570.88 / $11,481.54
| Facility | | $1,737.80 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,995.26 / $3,890.45
| Professional | | $1,584.89 | $1,995.26 | $3,890.45 |
- 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
- $1,412.54 / $2,187.76 / $4,466.84
| Professional | | $1,412.54 | $2,187.76 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $4,570.88 / $12,589.25
| Facility | | $323.59 | $4,570.88 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,754.23 / $5,248.07
| Professional | | $1,698.24 | $2,754.23 | $5,248.07 |
- 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
- $1,548.82 / $2,238.72 / $3,981.07
| Professional | | $1,548.82 | $2,238.72 | $3,981.07 |