- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $4,677.35 / $11,748.98
| Facility | | $1,659.59 | $4,677.35 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,819.70 / $3,467.37
| Professional | | $1,513.56 | $1,819.70 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $10,000.00 / $17,782.79
| Facility | | $3,630.78 | $10,000.00 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,862.09 / $3,630.78
| Professional | | $1,412.54 | $1,862.09 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $2,884.03 / $11,748.98
| Facility | | $371.54 | $2,884.03 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,290.87 / $4,677.35
| Professional | | $1,412.54 | $2,290.87 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $2,818.38 / $9,772.37
| Facility | | $537.03 | $2,818.38 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,949.84 / $3,548.13
| Professional | | $1,412.54 | $1,949.84 | $3,548.13 |