- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,467.37 / $4,897.79
| Facility | | $1,380.38 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $977.24 / $1,621.81
| Professional | | $812.83 | $977.24 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $14,125.38 / $19,054.61
| Facility | | $6,456.54 | $14,125.38 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,096.48 / $1,698.24
| Professional | | $831.76 | $1,096.48 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $912.01 / $1,023.29
| Facility | | $870.96 | $912.01 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,202.26 / $1,995.26
| Professional | | $870.96 | $1,202.26 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,000.00 / $1,698.24
| Professional | | $724.44 | $1,000.00 | $1,698.24 |