- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,659.59 / $2,041.74
| Facility | | $1,148.15 | $1,659.59 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,000.00 / $1,513.56
| Professional | | $870.96 | $1,000.00 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $9,120.11
| Facility | | $6,760.83 | $6,760.83 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,348.96
| Professional | | $1,023.29 | $1,023.29 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Facility | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,445.44 / $1,778.28
| Professional | | $812.83 | $1,445.44 | $1,778.28 |
- 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
- $870.96 / $1,258.93 / $1,905.46
| Professional | | $870.96 | $1,258.93 | $1,905.46 |