- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $5,370.32 / $7,413.10
| Facility | | $1,445.44 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $741.31 / $1,445.44
| Professional | | $602.56 | $741.31 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,754.23 / $6,025.60
| Facility | | $1,174.90 | $2,754.23 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,023.29 / $1,445.44
| Professional | | $645.65 | $1,023.29 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,148.15 / $2,187.76
| Facility | | $1,000.00 | $1,148.15 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,023.29 / $1,737.80
| Professional | | $691.83 | $1,023.29 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,023.29 / $3,715.35
| Professional | | $724.44 | $1,023.29 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $6,456.54 / $12,022.64
| Facility | | $1,737.80 | $6,456.54 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $870.96 / $1,513.56
| Professional | | $562.34 | $870.96 | $1,513.56 |