- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $7,079.46 / $14,125.38
| Facility | | $1,737.80 | $7,079.46 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $831.76 / $2,818.38
| Professional | | $478.63 | $831.76 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $2,290.87
| Professional | | $1,949.84 | $1,949.84 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $758.58 / $4,073.80
| Facility | | $524.81 | $758.58 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,949.84 / $2,511.89
| Professional | | $1,380.38 | $1,949.84 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,398.83 / $3,162.28
| Professional | | $1,479.11 | $2,398.83 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $831.76 / $4,073.80
| Facility | | $524.81 | $831.76 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $1,000.00 / $2,238.72
| Professional | | $60.26 | $1,000.00 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,548.82 / $2,344.23
| Professional | | $831.76 | $1,548.82 | $2,344.23 |