- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,890.45 / $7,943.28
| Facility | | $2,041.74 | $3,890.45 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $2,884.03
| Professional | | $933.25 | $1,122.02 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $5,370.32 / $7,943.28
| Facility | | $1,659.59 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $912.01 / $2,570.40
| Professional | | $812.83 | $912.01 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,258.93 / $2,137.96
| Professional | | $933.25 | $1,258.93 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,445.44 / $5,128.61
| Facility | | $1,000.00 | $1,445.44 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,174.90 / $7,244.36
| Professional | | $891.25 | $1,174.90 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,290.87 / $5,495.41
| Facility | | $1,348.96 | $2,290.87 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,071.52 / $1,949.84
| Professional | | $891.25 | $1,071.52 | $1,949.84 |