- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,570.40 / $5,888.44
| Facility | | $933.25 | $2,570.40 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,000.00 / $1,778.28
| Professional | | $794.33 | $1,000.00 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,248.07 / $7,762.47
| Facility | | $2,691.53 | $5,248.07 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,148.15 / $1,445.44
| Professional | | $933.25 | $1,148.15 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $831.76
| Facility | | $39.81 | $39.81 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Facility | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,230.27 / $1,659.59
| Professional | | $724.44 | $1,230.27 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,467.37 / $8,511.38
| Facility | | $1,023.29 | $3,467.37 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $977.24 / $1,584.89
| Professional | | $758.58 | $977.24 | $1,584.89 |