- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,073.80 / $7,762.47
| Facility | | $1,148.15 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,023.29 / $2,454.71
| Professional | | $870.96 | $1,023.29 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $2,818.38 / $6,456.54
| Professional | | $954.99 | $2,818.38 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,122.02 / $2,570.40
| Professional | | $851.14 | $1,122.02 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,862.09 / $2,089.30
| Professional | | $812.83 | $1,862.09 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $10,000.00 / $26,302.68
| Facility | | $2,344.23 | $10,000.00 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $933.25 / $2,454.71
| Professional | | $707.95 | $933.25 | $2,454.71 |