- 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
- $794.33 / $977.24 / $2,630.27
| Professional | | $794.33 | $977.24 | $2,630.27 |
- 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 / $851.14 / $2,630.27
| Professional | | $812.83 | $851.14 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $977.24 / $1,380.38
| Professional | | $812.83 | $977.24 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,513.56 / $5,128.61
| Facility | | $851.14 | $1,513.56 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,000.00 / $10,232.93
| Professional | | $794.33 | $1,000.00 | $10,232.93 |
- 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
- $776.25 / $933.25 / $1,445.44
| Professional | | $776.25 | $933.25 | $1,445.44 |