- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $5,754.40 / $14,125.38
| Facility | | $1,380.38 | $5,754.40 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $891.25 / $1,995.26
| Professional | | $758.58 | $891.25 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $7,585.78 / $14,791.08
| Facility | | $2,884.03 | $7,585.78 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,096.48 / $2,089.30
| Professional | | $776.25 | $1,096.48 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,187.76 / $6,165.95
| Facility | | $1,258.93 | $2,187.76 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,258.93 / $2,691.53
| Professional | | $812.83 | $1,258.93 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,265.80 / $10,000.00
| Facility | | $1,513.56 | $4,265.80 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,000.00 / $1,905.46
| Professional | | $724.44 | $1,000.00 | $1,905.46 |