- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,630.78 / $7,244.36
| Facility | | $933.25 | $3,630.78 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,047.13 / $1,479.11
| Professional | | $794.33 | $1,047.13 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,000.00 / $5,370.32
| Facility | | $676.08 | $1,000.00 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,949.84 / $6,456.54
| Professional | | $1,621.81 | $1,949.84 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $1,148.15
| Professional | | $794.33 | $794.33 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $1,071.52 / $1,202.26
| Professional | | $50.12 | $1,071.52 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $1,202.26 / $1,348.96
| Facility | | $562.34 | $1,202.26 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $562.34 / $1,995.26
| Professional | | $467.74 | $562.34 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $794.33 / $794.33
| Professional | | $363.08 | $794.33 | $794.33 |