- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,388.44 / $6,025.60
| Facility | | $1,445.44 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,202.26 / $2,238.72
| Professional | | $1,000.00 | $1,202.26 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,479.11 / $1,905.46
| Professional | | $1,258.93 | $1,479.11 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $60.26 / $5,754.40
| Professional | | $32.36 | $60.26 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,041.74 / $5,495.41
| Professional | | $1,318.26 | $2,041.74 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $2,344.23 / $3,235.94
| Professional | | $933.25 | $2,344.23 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,621.81 / $4,786.30
| Professional | | $1,380.38 | $1,621.81 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,128.61 / $24,547.09
| Facility | | $3,311.31 | $5,128.61 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,318.26 / $2,137.96
| Professional | | $977.24 | $1,318.26 | $2,137.96 |