- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,058.25 / $4,001.00 / $8,066.50
| Facility | | $1,058.25 | $4,001.00 | $8,066.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $825.44 / $928.17 / $1,445.57
| Professional | | $825.44 | $928.17 | $1,445.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,046.00 / $7,363.00 / $12,538.00
| Facility | | $4,046.00 | $7,363.00 | $12,538.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.13 / $1,081.76 / $1,828.62
| Professional | | $871.13 | $1,081.76 | $1,828.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,032.63 / $1,445.42 / $3,461.80
| Facility | | $1,032.63 | $1,445.42 | $3,461.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $918.77 / $1,302.27 / $2,008.72
| Professional | | $918.77 | $1,302.27 | $2,008.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $6,231.00 / $11,869.99
| Facility | | $2,912.00 | $6,231.00 | $11,869.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.07 / $1,155.42 / $2,003.09
| Professional | | $815.07 | $1,155.42 | $2,003.09 |