- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $4,570.88 / $10,964.78
| Facility | | $1,737.80 | $4,570.88 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,995.26 / $3,715.35
| Professional | | $1,698.24 | $1,995.26 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $10,000.00 / $19,498.45
| Facility | | $3,467.37 | $10,000.00 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,137.96 / $4,073.80
| Professional | | $1,621.81 | $2,137.96 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $3,162.28 / $7,762.47
| Facility | | $398.11 | $3,162.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,511.89 / $5,248.07
| Professional | | $1,513.56 | $2,511.89 | $5,248.07 |
- 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
- $1,548.82 / $2,187.76 / $3,890.45
| Professional | | $1,548.82 | $2,187.76 | $3,890.45 |