- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,365.16 / $10,964.78
| Facility | | $1,122.02 | $4,365.16 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $912.01 / $1,995.26
| Professional | | $758.58 | $912.01 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $7,244.36 / $14,454.40
| Facility | | $2,754.23 | $7,244.36 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,122.02 / $2,137.96
| Professional | | $741.31 | $1,122.02 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,862.09 / $6,456.54
| Facility | | $977.24 | $1,862.09 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,258.93 / $2,754.23
| Professional | | $831.76 | $1,258.93 | $2,754.23 |
- 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
- $707.95 / $977.24 / $1,862.09
| Professional | | $707.95 | $977.24 | $1,862.09 |