- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $3,715.35 / $9,549.93
| Facility | | $1,071.52 | $3,715.35 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $912.01 / $1,995.26
| Professional | | $741.31 | $912.01 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $6,165.95 / $14,125.38
| Facility | | $1,995.26 | $6,165.95 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,071.52 / $1,995.26
| Professional | | $691.83 | $1,071.52 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,344.23 / $5,754.40
| Facility | | $1,122.02 | $2,344.23 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,230.27 / $2,630.27
| Professional | | $758.58 | $1,230.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,754.40 / $13,489.63
| Facility | | $1,995.26 | $5,754.40 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,000.00 / $1,862.09
| Professional | | $691.83 | $1,000.00 | $1,862.09 |