- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $5,754.40 / $14,125.38
| Facility | | $1,071.52 | $5,754.40 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $478.63 / $1,122.02
| Professional | | $407.38 | $478.63 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $10,000.00 / $19,498.45
| Facility | | $3,467.37 | $10,000.00 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $616.60 / $1,122.02
| Professional | | $407.38 | $616.60 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,445.44 / $3,388.44
| Facility | | $724.44 | $1,445.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $676.08 / $1,445.44
| Professional | | $446.68 | $676.08 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $12,302.69
| Facility | | $1,949.84 | $5,495.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $537.03 / $1,000.00
| Professional | | $380.19 | $537.03 | $1,000.00 |