- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,884.03 / $4,897.79
| Facility | | $2,041.74 | $2,884.03 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $478.63 / $3,235.94
| Professional | | $177.83 | $478.63 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $426.58 / $426.58
| Facility | | $138.04 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $1,023.29 / $1,023.29
| Professional | | $426.58 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $478.63 / $4,168.69
| Professional | | $186.21 | $478.63 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $2,041.74 / $4,897.79
| Facility | | $501.19 | $2,041.74 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $436.52 / $5,370.32
| Professional | | $218.78 | $436.52 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $478.63 / $3,715.35
| Professional | | $186.21 | $478.63 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $10,000.00 / $29,512.09
| Facility | | $5,011.87 | $10,000.00 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $263.03 / $2,454.71
| Professional | | $181.97 | $263.03 | $2,454.71 |