- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,365.16 / $10,964.78
| Facility | | $1,148.15 | $4,365.16 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $891.25 / $2,187.76
| Professional | | $776.25 | $891.25 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $7,413.10 / $16,218.10
| Facility | | $2,398.83 | $7,413.10 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,122.02 / $2,137.96
| Professional | | $776.25 | $1,122.02 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,691.53 / $6,309.57
| Facility | | $1,445.44 | $2,691.53 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,288.25 / $2,754.23
| Professional | | $831.76 | $1,288.25 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $7,244.36 / $16,218.10
| Facility | | $2,454.71 | $7,244.36 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,000.00 / $1,905.46
| Professional | | $724.44 | $1,000.00 | $1,905.46 |