- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,700.96 / $3,997.26 / $6,548.70
| Facility | | $1,700.96 | $3,997.26 | $6,548.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,488.34 / $1,700.96 / $1,743.48
| Professional | | $1,488.34 | $1,700.96 | $1,743.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.97 / $24.53 / $2,759.80
| Professional | | $17.97 | $24.53 | $2,759.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.19 / $6,219.14 / $49,753.08
| Facility | | $2,126.19 | $6,219.14 | $49,753.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,222.60 / $5,102.88 / $50,008.59
| Professional | | $2,222.60 | $5,102.88 | $50,008.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,418.55 / $4,477.78 / $14,334.55
| Facility | | $2,418.55 | $4,477.78 | $14,334.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,418.55 / $4,477.78 / $14,334.55
| Facility | | $2,418.55 | $4,477.78 | $14,334.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.72 / $2,126.19 / $2,126.19
| Facility | | $1,275.72 | $2,126.19 | $2,126.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.00 / $1,275.72 / $2,808.07
| Professional | | $893.00 | $1,275.72 | $2,808.07 |