- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,918.31 / $10,964.78
| Facility | | $4,365.16 | $6,918.31 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $912.01 / $3,235.94
| Professional | | $776.25 | $912.01 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $2,818.38
| Professional | | $812.83 | $1,174.90 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,023.29 / $1,412.54
| Professional | | $812.83 | $1,023.29 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,302.68 / $41,686.94 / $66,069.34
| Facility | | $26,302.68 | $41,686.94 | $66,069.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,096.48 / $3,630.78
| Professional | | $794.33 | $1,096.48 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $10,000.00 / $25,118.86
| Facility | | $4,786.30 | $10,000.00 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $912.01 / $2,238.72
| Professional | | $676.08 | $912.01 | $2,238.72 |