- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,786.30 / $11,481.54
| Facility | | $1,202.26 | $4,786.30 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $776.25 / $1,737.80
| Professional | | $691.83 | $776.25 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $7,585.78 / $14,791.08
| Facility | | $2,691.53 | $7,585.78 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,000.00 / $1,862.09
| Professional | | $660.69 | $1,000.00 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,290.87 / $5,495.41
| Facility | | $1,288.25 | $2,290.87 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,122.02 / $2,344.23
| Professional | | $741.31 | $1,122.02 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,918.31 / $15,488.17
| Facility | | $2,398.83 | $6,918.31 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $891.25 / $1,621.81
| Professional | | $630.96 | $891.25 | $1,621.81 |