- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,370.32 / $7,413.10
| Facility | | $1,202.26 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $776.25 / $1,348.96
| Professional | | $602.56 | $776.25 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,365.16 / $10,000.00
| Facility | | $1,513.56 | $4,365.16 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,096.48 / $1,621.81
| Professional | | $630.96 | $1,096.48 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,148.15 / $1,862.09
| Professional | | $645.65 | $1,148.15 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $812.83 / $1,698.24
| Professional | | $645.65 | $812.83 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,754.40 / $8,511.38
| Facility | | $1,513.56 | $5,754.40 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $954.99 / $1,548.82
| Professional | | $676.08 | $954.99 | $1,548.82 |