- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,128.61 / $12,022.64
| Facility | | $1,202.26 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $851.14 / $1,862.09
| Professional | | $707.95 | $851.14 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $10,000.00 / $18,620.87
| Facility | | $3,630.78 | $10,000.00 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,096.48 / $1,995.26
| Professional | | $724.44 | $1,096.48 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $2,454.71 / $7,079.46
| Facility | | $323.59 | $2,454.71 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,230.27 / $2,630.27
| Professional | | $776.25 | $1,230.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,128.61 / $12,022.64
| Facility | | $1,905.46 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,023.29 / $1,862.09
| Professional | | $724.44 | $1,023.29 | $1,862.09 |