- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,623.41 / $7,413.10
| Facility | | $3,162.28 | $5,623.41 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $537.03 / $954.99
| Professional | | $436.52 | $537.03 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $6,456.54 / $32,359.37
| Facility | | $2,238.72 | $6,456.54 | $32,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $758.58 / $1,023.29
| Professional | | $489.78 | $758.58 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $758.58 / $1,258.93
| Professional | | $562.34 | $758.58 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $549.54 / $4,570.88
| Professional | | $478.63 | $549.54 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $10,000.00 / $70,794.58
| Facility | | $2,884.03 | $10,000.00 | $70,794.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $741.31 / $1,202.26
| Professional | | $478.63 | $741.31 | $1,202.26 |