- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,248.07 / $10,471.29
| Facility | | $2,089.30 | $5,248.07 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $776.25 / $1,621.81
| Professional | | $446.68 | $776.25 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,348.96
| Professional | | $1,122.02 | $1,122.02 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,000.00 / $4,897.79
| Facility | | $691.83 | $1,000.00 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $707.95 / $6,456.54
| Professional | | $281.84 | $707.95 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,981.07 / $6,309.57
| Facility | | $1,230.27 | $3,981.07 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $501.19 / $1,148.15
| Professional | | $281.84 | $501.19 | $1,148.15 |