- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,715.35 / $9,772.37
| Facility | | $1,047.13 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $812.83 / $1,513.56
| Professional | | $676.08 | $812.83 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $6,456.54 / $13,803.84
| Facility | | $2,691.53 | $6,456.54 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $912.01 / $1,659.59
| Professional | | $645.65 | $912.01 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $1,318.26 / $3,630.78
| Facility | | $426.58 | $1,318.26 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,000.00 / $2,137.96
| Professional | | $645.65 | $1,000.00 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,454.71 / $6,025.60
| Facility | | $645.65 | $2,454.71 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $851.14 / $1,513.56
| Professional | | $602.56 | $851.14 | $1,513.56 |