- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $4,466.84 / $10,964.78
| Facility | | $1,071.52 | $4,466.84 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $851.14 / $2,238.72
| Professional | | $660.69 | $851.14 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $7,244.36 / $16,982.44
| Facility | | $3,388.44 | $7,244.36 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,047.13 / $1,905.46
| Professional | | $724.44 | $1,047.13 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,949.84 / $5,623.41
| Facility | | $398.11 | $1,949.84 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,202.26 / $2,570.40
| Professional | | $776.25 | $1,202.26 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,248.07 / $12,302.69
| Facility | | $1,905.46 | $5,248.07 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,000.00 / $1,819.70
| Professional | | $707.95 | $1,000.00 | $1,819.70 |