- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $930.15 / $2,325.38 / $10,038.60
| Facility | | $930.15 | $2,325.38 | $10,038.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.15 / $1,368.90 / $1,491.75
| Professional | | $930.15 | $1,368.90 | $1,491.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,715.51 / $2,220.08 / $5,920.01
| Facility | | $1,715.51 | $2,220.08 | $5,920.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.75 / $2,299.05 / $3,197.61
| Professional | | $1,842.75 | $2,299.05 | $3,197.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,228.50 / $1,755.00 / $8,702.00
| Facility | | $1,228.50 | $1,755.00 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,228.50 / $1,228.50 / $1,228.50
| Professional | | $1,228.50 | $1,228.50 | $1,228.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,053.00 / $1,755.00 / $3,510.00
| Facility | | $1,053.00 | $1,755.00 | $3,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.00 / $1,053.00 / $1,798.88
| Professional | | $702.00 | $1,053.00 | $1,798.88 |