- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.73 / $3,392.50 / $8,074.63
| Facility | | $912.73 | $3,392.50 | $8,074.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.16 / $847.02 / $1,263.89
| Professional | | $752.16 | $847.02 | $1,263.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,879.72 / $8,490.10 / $13,618.42
| Facility | | $3,879.72 | $8,490.10 | $13,618.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.37 / $1,020.10 / $1,561.89
| Professional | | $759.37 | $1,020.10 | $1,561.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.50 / $875.50 / $1,209.33
| Facility | | $875.50 | $875.50 | $1,209.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.54 / $1,153.49 / $1,866.85
| Professional | | $788.54 | $1,153.49 | $1,866.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,876.00 / $4,674.00 / $9,018.50
| Facility | | $2,876.00 | $4,674.00 | $9,018.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.97 / $1,080.82 / $1,801.43
| Professional | | $767.97 | $1,080.82 | $1,801.43 |