- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,548.82 / $2,041.74
| Facility | | $1,047.13 | $1,548.82 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $870.96 / $1,258.93
| Professional | | $776.25 | $870.96 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $7,413.10
| Facility | | $5,370.32 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $1,230.27
| Professional | | $912.01 | $912.01 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,288.25 / $1,513.56
| Professional | | $707.95 | $1,288.25 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,981.07 / $11,748.98
| Facility | | $1,548.82 | $3,981.07 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,000.00 / $1,621.81
| Professional | | $794.33 | $1,000.00 | $1,621.81 |