- 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
- $741.31 / $891.25 / $1,862.09
| Professional | | $741.31 | $891.25 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $7,943.28 / $14,791.08
| Facility | | $2,754.23 | $7,943.28 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,148.15 / $2,089.30
| Professional | | $758.58 | $1,148.15 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,187.76 / $6,165.95
| Facility | | $398.11 | $2,187.76 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,318.26 / $2,754.23
| Professional | | $812.83 | $1,318.26 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,265.80 / $10,000.00
| Facility | | $1,584.89 | $4,265.80 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,096.48 / $1,949.84
| Professional | | $758.58 | $1,096.48 | $1,949.84 |