- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $3,981.07 / $7,762.47
| Facility | | $977.24 | $3,981.07 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $977.24 / $1,584.89
| Professional | | $691.83 | $977.24 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,128.31 / $8,128.31
| Facility | | $4,570.88 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $1,380.38
| Professional | | $776.25 | $1,000.00 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,096.48 / $1,698.24
| Professional | | $707.95 | $1,096.48 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.14 / $1,096.48 / $3,630.78
| Professional | | $15.14 | $1,096.48 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,659.59 / $6,456.54
| Professional | | $1,000.00 | $1,659.59 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,096.48 / $1,819.70
| Professional | | $660.69 | $1,096.48 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,548.13 / $10,715.19
| Facility | | $2,290.87 | $3,548.13 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $977.24 / $1,548.82
| Professional | | $691.83 | $977.24 | $1,548.82 |