- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $7,762.47 / $14,791.08
| Facility | | $1,995.26 | $7,762.47 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $676.08 / $2,238.72
| Professional | | $575.44 | $676.08 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,238.72
| Professional | | $1,905.46 | $1,905.46 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,162.28 / $7,762.47
| Facility | | $2,238.72 | $3,162.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,621.81 / $2,041.74
| Professional | | $660.69 | $1,621.81 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,570.40 / $5,495.41
| Professional | | $2,398.83 | $2,570.40 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,238.72 / $3,162.28
| Facility | | $1,096.48 | $2,238.72 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $870.96 / $2,238.72
| Professional | | $60.26 | $870.96 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,778.28 / $10,232.93
| Professional | | $891.25 | $1,778.28 | $10,232.93 |