- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,365.16 / $10,964.78
| Facility | | $1,148.15 | $4,365.16 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $870.96 / $1,905.46
| Professional | | $741.31 | $870.96 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $6,456.54 / $12,589.25
| Facility | | $2,511.89 | $6,456.54 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,047.13 / $1,995.26
| Professional | | $707.95 | $1,047.13 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,290.87 / $6,165.95
| Facility | | $1,258.93 | $2,290.87 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,258.93 / $2,754.23
| Professional | | $776.25 | $1,258.93 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,365.16 / $10,000.00
| Facility | | $1,584.89 | $4,365.16 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,000.00 / $1,862.09
| Professional | | $691.83 | $1,000.00 | $1,862.09 |