- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $5,370.32 / $7,413.10
| Facility | | $1,318.26 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $851.14 / $1,548.82
| Professional | | $660.69 | $851.14 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $4,265.80 / $12,022.64
| Facility | | $1,258.93 | $4,265.80 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,258.93 / $1,778.28
| Professional | | $758.58 | $1,258.93 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $11,481.54
| Facility | | $1,000.00 | $1,258.93 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,202.26 / $1,905.46
| Professional | | $794.33 | $1,202.26 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,148.15 / $4,073.80
| Professional | | $794.33 | $1,148.15 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $6,918.31 / $12,022.64
| Facility | | $1,737.80 | $6,918.31 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,071.52 / $1,778.28
| Professional | | $660.69 | $1,071.52 | $1,778.28 |