- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,079.46 / $14,125.38
| Facility | | $4,365.16 | $7,079.46 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $954.99 / $1,905.46
| Professional | | $758.58 | $954.99 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,168.69 / $12,022.64
| Facility | | $3,715.35 | $4,168.69 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,584.89 / $2,089.30
| Professional | | $794.33 | $1,584.89 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,479.11 / $2,089.30
| Professional | | $1,000.00 | $1,479.11 | $2,089.30 |
- 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
- $4,570.88 / $7,079.46 / $11,220.18
| Facility | | $4,570.88 | $7,079.46 | $11,220.18 |
- 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 |