- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,897.79 / $4,897.79
| Facility | | $1,380.38 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $870.96 / $2,137.96
| Professional | | $354.81 | $870.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $10,000.00 / $13,182.57
| Facility | | $2,398.83 | $10,000.00 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $3,715.35
| Professional | | $2,041.74 | $2,398.83 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $8,511.38 / $43,651.58
| Facility | | $537.03 | $8,511.38 | $43,651.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $6,025.60 / $10,715.19
| Facility | | $2,691.53 | $6,025.60 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,187.76 / $3,548.13
| Professional | | $1,584.89 | $2,187.76 | $3,548.13 |