- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $4,897.79 / $12,022.64
| Facility | | $1,348.96 | $4,897.79 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,000.00 / $2,187.76
| Professional | | $870.96 | $1,000.00 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $10,471.29 / $22,908.68
| Facility | | $3,548.13 | $10,471.29 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,288.25 / $2,398.83
| Professional | | $870.96 | $1,288.25 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,691.53 / $8,511.38
| Facility | | $1,174.90 | $2,691.53 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,412.54 / $3,019.95
| Professional | | $954.99 | $1,412.54 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $7,244.36 / $16,982.44
| Facility | | $2,454.71 | $7,244.36 | $16,982.44 |
- 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 |