- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $5,495.41 / $14,454.40
| Facility | | $891.25 | $5,495.41 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $660.69 / $1,122.02
| Professional | | $501.19 | $660.69 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,412.54
| Professional | | $1,174.90 | $1,174.90 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $977.24
| Facility | | $977.24 | $977.24 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $831.76 / $1,288.25
| Professional | | $645.65 | $831.76 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $933.25 / $4,466.84
| Facility | | $575.44 | $933.25 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,000.00 / $5,754.40
| Professional | | $676.08 | $1,000.00 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,570.40 / $4,677.35
| Facility | | $1,548.82 | $2,570.40 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $794.33 / $1,096.48
| Professional | | $602.56 | $794.33 | $1,096.48 |