- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,897.79 / $6,918.31
| Facility | | $1,318.26 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,071.52 / $1,995.26
| Professional | | $912.01 | $1,071.52 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $1,513.56
| Facility | | $309.03 | $309.03 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $1,513.56 / $1,513.56
| Professional | | $309.03 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,258.93 / $2,754.23
| Professional | | $794.33 | $1,258.93 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,630.78 / $6,918.31
| Facility | | $1,318.26 | $3,630.78 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,288.25 / $1,905.46
| Professional | | $977.24 | $1,288.25 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,230.27 / $1,905.46
| Professional | | $758.58 | $1,230.27 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $10,000.00 / $19,054.61
| Facility | | $5,011.87 | $10,000.00 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,288.25 / $1,621.81
| Professional | | $977.24 | $1,288.25 | $1,621.81 |