- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $5,248.07 / $12,022.64
| Facility | | $1,122.02 | $5,248.07 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $707.95 / $1,584.89
| Professional | | $602.56 | $707.95 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $11,220.18 / $22,387.21
| Facility | | $3,715.35 | $11,220.18 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $891.25 / $1,659.59
| Professional | | $616.60 | $891.25 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,089.30 / $5,754.40
| Facility | | $933.25 | $2,089.30 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,000.00 / $2,137.96
| Professional | | $660.69 | $1,000.00 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,754.40 / $14,125.38
| Facility | | $1,949.84 | $5,754.40 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $794.33 / $1,479.11
| Professional | | $562.34 | $794.33 | $1,479.11 |