- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $6,025.60 / $14,125.38
| Facility | | $1,047.13 | $6,025.60 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $1,230.27 / $3,548.13
| Professional | | $158.49 | $1,230.27 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $11,748.98 / $53,703.18
| Facility | | $398.11 | $11,748.98 | $53,703.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,412.54
| Professional | | $1,380.38 | $1,380.38 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $12,022.64 / $23,442.29
| Facility | | $6,165.95 | $12,022.64 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $537.03 / $812.83
| Professional | | $398.11 | $537.03 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $10,000.00 / $15,848.93
| Facility | | $2,818.38 | $10,000.00 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $39.81 / $60.26
| Professional | | $34.67 | $39.81 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $426.58
| Professional | | $426.58 | $426.58 | $426.58 |