- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,388.44 / $4,897.79
| Facility | | $1,659.59 | $3,388.44 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $812.83 / $1,737.80
| Professional | | $208.93 | $812.83 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $1,000.00 / $1,905.46
| Professional | | $257.04 | $1,000.00 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $724.44
| Professional | | $32.36 | $33.11 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $1,258.93 / $2,344.23
| Professional | | $275.42 | $1,258.93 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $1,000.00 / $2,454.71
| Professional | | $398.11 | $1,000.00 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $1,412.54 / $2,137.96
| Professional | | $288.40 | $1,412.54 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $4,466.84 / $5,128.61
| Facility | | $1,071.52 | $4,466.84 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $630.96 / $1,778.28
| Professional | | $218.78 | $630.96 | $1,778.28 |