- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,370.32 / $9,549.93
| Facility | | $1,202.26 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,000.00 / $1,995.26
| Professional | | $758.58 | $1,000.00 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,238.72 / $3,548.13
| Facility | | $794.33 | $2,238.72 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,348.96 / $1,905.46
| Professional | | $794.33 | $1,348.96 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,479.11 / $2,398.83
| Professional | | $933.25 | $1,479.11 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $977.24 / $2,754.23
| Professional | | $812.83 | $977.24 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Professional | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $2,238.72 / $3,467.37
| Facility | | $776.25 | $2,238.72 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,202.26 / $2,290.87
| Professional | | $891.25 | $1,202.26 | $2,290.87 |