- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,570.88 / $11,220.18
| Facility | | $1,202.26 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,148.15 / $2,137.96
| Professional | | $977.24 | $1,148.15 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $10,000.00 / $20,892.96
| Facility | | $3,548.13 | $10,000.00 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,230.27 / $2,290.87
| Professional | | $912.01 | $1,230.27 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,819.70 / $4,897.79
| Facility | | $398.11 | $1,819.70 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,412.54 / $2,884.03
| Professional | | $891.25 | $1,412.54 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $2,818.38 / $9,772.37
| Facility | | $537.03 | $2,818.38 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $2,238.72
| Professional | | $891.25 | $1,230.27 | $2,238.72 |