- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $10,964.78 / $16,595.87
| Facility | | $2,187.76 | $10,964.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $912.01 / $2,187.76
| Professional | | $645.65 | $912.01 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $3,162.28
| Professional | | $1,778.28 | $2,398.83 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,071.52 / $5,011.87
| Facility | | $660.69 | $1,071.52 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,511.89 / $4,073.80
| Professional | | $1,737.80 | $2,511.89 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,019.95 / $4,168.69
| Professional | | $2,344.23 | $3,019.95 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,071.52 / $3,890.45
| Facility | | $660.69 | $1,071.52 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $1,000.00 / $2,398.83
| Professional | | $60.26 | $1,000.00 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $2,884.03 / $4,168.69
| Professional | | $831.76 | $2,884.03 | $4,168.69 |