- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,570.88 / $11,481.54
| Facility | | $1,122.02 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,000.00 / $2,137.96
| Professional | | $870.96 | $1,000.00 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $12,589.25 / $24,547.09
| Facility | | $4,365.16 | $12,589.25 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,258.93 / $2,398.83
| Professional | | $870.96 | $1,258.93 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $2,630.27 / $6,918.31
| Facility | | $323.59 | $2,630.27 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,445.44 / $3,090.30
| Professional | | $954.99 | $1,445.44 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $8,709.64 / $19,054.61
| Facility | | $2,951.21 | $8,709.64 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $2,137.96
| Professional | | $812.83 | $1,148.15 | $2,137.96 |