- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,890.45 / $7,762.47
| Facility | | $1,288.25 | $3,890.45 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $870.96 / $1,479.11
| Professional | | $645.65 | $870.96 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Facility | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,000.00 / $1,258.93
| Professional | | $724.44 | $1,000.00 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,412.54 / $7,244.36
| Facility | | $870.96 | $1,412.54 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $891.25 / $6,309.57
| Professional | | $676.08 | $891.25 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,265.80 / $8,317.64
| Facility | | $1,230.27 | $4,265.80 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $776.25 / $1,071.52
| Professional | | $602.56 | $776.25 | $1,071.52 |