- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,677.35 / $11,481.54
| Facility | | $1,819.70 | $4,677.35 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,754.23 / $4,897.79
| Professional | | $1,819.70 | $2,754.23 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $10,000.00 / $18,197.01
| Facility | | $3,890.45 | $10,000.00 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,754.23 / $5,623.41
| Professional | | $1,737.80 | $2,754.23 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $5,623.41 / $15,848.93
| Facility | | $398.11 | $5,623.41 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,630.78 / $7,762.47
| Professional | | $1,905.46 | $3,630.78 | $7,762.47 |
- 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
- $1,737.80 / $2,691.53 / $5,495.41
| Professional | | $1,737.80 | $2,691.53 | $5,495.41 |