- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,398.83 / $7,585.78
| Facility | | $758.58 | $2,398.83 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $501.19 / $812.83
| Professional | | $239.88 | $501.19 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,951.21 / $3,801.89
| Facility | | $1,548.82 | $2,951.21 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $562.34 / $1,047.13
| Professional | | $295.12 | $562.34 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Facility | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $478.63 / $912.01
| Professional | | $275.42 | $478.63 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $28,840.32
| Facility | | $5,495.41 | $5,495.41 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,265.80
| Professional | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,630.78 / $6,309.57
| Facility | | $1,995.26 | $3,630.78 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $501.19 / $1,000.00
| Professional | | $245.47 | $501.19 | $1,000.00 |