- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,754.23 / $4,073.80
| Facility | | $1,148.15 | $2,754.23 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $851.14 / $3,019.95
| Professional | | $371.54 | $851.14 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $457.09 / $4,073.80
| Professional | | $380.19 | $457.09 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $891.25 / $3,801.89
| Professional | | $389.05 | $891.25 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,071.52 / $2,041.74
| Professional | | $912.01 | $1,071.52 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $10,000.00 / $26,302.68
| Facility | | $1,819.70 | $10,000.00 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $912.01 / $3,090.30
| Professional | | $354.81 | $912.01 | $3,090.30 |