- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,570.88 / $11,220.18
| Facility | | $1,584.89 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,698.24 / $3,388.44
| Professional | | $1,380.38 | $1,698.24 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $10,000.00 / $18,197.01
| Facility | | $4,073.80 | $10,000.00 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,041.74 / $3,890.45
| Professional | | $1,348.96 | $2,041.74 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $4,168.69 / $11,481.54
| Facility | | $323.59 | $4,168.69 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,398.83 / $4,677.35
| Professional | | $1,479.11 | $2,398.83 | $4,677.35 |
- 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
- $1,348.96 / $1,949.84 / $3,548.13
| Professional | | $1,348.96 | $1,949.84 | $3,548.13 |