- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,466.84 / $10,964.78
| Facility | | $1,148.15 | $4,466.84 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $891.25 / $1,949.84
| Professional | | $758.58 | $891.25 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $7,413.10 / $15,135.61
| Facility | | $2,884.03 | $7,413.10 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $2,137.96
| Professional | | $741.31 | $1,047.13 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $2,187.76 / $7,413.10
| Facility | | $512.86 | $2,187.76 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,258.93 / $2,691.53
| Professional | | $831.76 | $1,258.93 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $8,709.64 / $19,054.61
| Facility | | $3,019.95 | $8,709.64 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,000.00 / $1,905.46
| Professional | | $707.95 | $1,000.00 | $1,905.46 |