- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $5,128.61 / $11,481.54
| Facility | | $1,621.81 | $5,128.61 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $6,606.93 / $6,606.93
| Professional | | $1,230.27 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,495.41 / $12,022.64
| Facility | | $2,290.87 | $5,495.41 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $316.23 / $331.13
| Professional | | $295.12 | $316.23 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $562.34 / $1,778.28
| Facility | | $64.57 | $562.34 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Professional | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,981.07 / $10,000.00
| Facility | | $1,047.13 | $3,981.07 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $6,760.83 / $11,481.54
| Professional | | $2,511.89 | $6,760.83 | $11,481.54 |