- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,570.88 / $11,481.54
| Facility | | $1,698.24 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,949.84 / $3,890.45
| Professional | | $1,584.89 | $1,949.84 | $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
- $1,479.11 / $2,238.72 / $4,365.16
| Professional | | $1,479.11 | $2,238.72 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $4,168.69 / $10,715.19
| Facility | | $398.11 | $4,168.69 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,691.53 / $5,248.07
| Professional | | $1,698.24 | $2,691.53 | $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 |