- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,677.35 / $11,481.54
| Facility | | $1,584.89 | $4,677.35 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,698.24 / $3,801.89
| Professional | | $1,412.54 | $1,698.24 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $10,000.00 / $20,892.96
| Facility | | $3,630.78 | $10,000.00 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,137.96 / $4,073.80
| Professional | | $1,412.54 | $2,137.96 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,570.88 / $12,882.50
| Facility | | $2,754.23 | $4,570.88 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,511.89 / $5,370.32
| Professional | | $1,548.82 | $2,511.89 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $7,079.46 / $15,488.17
| Facility | | $2,454.71 | $7,079.46 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,041.74 / $3,890.45
| Professional | | $1,412.54 | $2,041.74 | $3,890.45 |