- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,495.41 / $10,964.78
| Facility | | $1,202.26 | $5,495.41 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $1,202.26 / $2,454.71
| Professional | | $398.11 | $1,202.26 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $398.11 / $1,862.09
| Facility | | $323.59 | $398.11 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Professional | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,122.02 / $1,122.02
| Professional | | $562.34 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $1,659.59 / $1,995.26
| Professional | | $50.12 | $1,659.59 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $5,128.61 / $10,715.19
| Facility | | $676.08 | $5,128.61 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,380.38 / $2,454.71
| Professional | | $933.25 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Professional | | $630.96 | $630.96 | $630.96 |