- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $7,762.47
| Facility | | $1,513.56 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,380.38 / $2,454.71
| Professional | | $1,174.90 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,412.54 / $2,238.72
| Professional | | $707.95 | $1,412.54 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $3,630.78
| Professional | | $1,096.48 | $1,445.44 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,318.26 / $2,884.03
| Professional | | $1,258.93 | $1,318.26 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $10,000.00 / $33,884.42
| Facility | | $4,073.80 | $10,000.00 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,380.38 / $3,162.28
| Professional | | $1,023.29 | $1,380.38 | $3,162.28 |