- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $4,570.88 / $11,481.54
| Facility | | $1,258.93 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,258.93 / $3,019.95
| Professional | | $1,071.52 | $1,258.93 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $10,000.00 / $21,877.62
| Facility | | $3,630.78 | $10,000.00 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $3,019.95
| Professional | | $1,096.48 | $1,548.82 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $3,235.94 / $8,912.51
| Facility | | $323.59 | $3,235.94 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,778.28 / $3,890.45
| Professional | | $1,148.15 | $1,778.28 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $3,162.28 / $10,232.93
| Facility | | $812.83 | $3,162.28 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $2,754.23
| Professional | | $1,023.29 | $1,445.44 | $2,754.23 |