- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,786.30 / $7,079.46
| Facility | | $1,445.44 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,513.56 / $1,995.26
| Professional | | $1,348.96 | $1,513.56 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,041.74 / $3,548.13
| Professional | | $1,047.13 | $2,041.74 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $11,481.54 / $28,183.83
| Facility | | $1,949.84 | $11,481.54 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,202.26 / $11,748.98
| Professional | | $630.96 | $1,202.26 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $2,041.74 / $3,388.44
| Professional | | $354.81 | $2,041.74 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $7.08 / $7.08
| Professional | | $7.08 | $7.08 | $7.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $13,489.63 / $28,183.83
| Facility | | $8,511.38 | $13,489.63 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,000.00 / $2,137.96
| Professional | | $630.96 | $1,000.00 | $2,137.96 |