- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,907.20 / $14,796.00 / $38,847.31
| Facility | | $5,907.20 | $14,796.00 | $38,847.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,216.90 / $4,722.00 / $9,251.04
| Professional | | $2,216.90 | $4,722.00 | $9,251.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.01 / $20.01 / $30.76
| Professional | | $20.01 | $20.01 | $30.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.50 / $1,326.50 / $1,326.50
| Professional | | $1,326.50 | $1,326.50 | $1,326.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,356.98 / $3,859.17 / $3,918.51
| Facility | | $2,356.98 | $3,859.17 | $3,918.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.00 / $155.00 / $329.00
| Professional | | $155.00 | $155.00 | $329.00 |