- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,436.28 / $4,933.00 / $6,853.00
| Facility | | $1,436.28 | $4,933.00 | $6,853.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.80 / $1,436.28 / $2,958.20
| Professional | | $1,071.80 | $1,436.28 | $2,958.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $771.77 / $1,145.64 / $2,516.84
| Facility | | $771.77 | $1,145.64 | $2,516.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.72 / $1,527.11 / $2,170.10
| Professional | | $272.72 | $1,527.11 | $2,170.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.29 / $1,523.16 / $2,163.38
| Professional | | $973.29 | $1,523.16 | $2,163.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.96 / $4,933.00 / $6,853.00
| Facility | | $1,174.96 | $4,933.00 | $6,853.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.17 / $1,229.25 / $1,935.12
| Professional | | $1,107.17 | $1,229.25 | $1,935.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.02 / $866.18 / $1,346.13
| Professional | | $69.02 | $866.18 | $1,346.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,000.00 / $10,192.00 / $14,705.00
| Facility | | $5,000.00 | $10,192.00 | $14,705.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,135.38 / $1,381.64 / $2,141.71
| Professional | | $1,135.38 | $1,381.64 | $2,141.71 |