- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,918.31 / $11,748.98
| Facility | | $4,365.16 | $6,918.31 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $3,019.95
| Professional | | $1,479.11 | $1,737.80 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,290.87 / $5,495.41
| Professional | | $1,202.26 | $2,290.87 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,041.74 / $2,691.53
| Professional | | $1,513.56 | $2,041.74 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $2,691.53 / $25,703.96
| Facility | | $158.49 | $2,691.53 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $3,890.45
| Professional | | $1,318.26 | $1,905.46 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,888.44 / $10,471.29
| Facility | | $1,698.24 | $5,888.44 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,548.82 / $3,311.31
| Professional | | $1,000.00 | $1,548.82 | $3,311.31 |