- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,698.24 / $2,454.71
| Facility | | $1,148.15 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,000.00 / $1,445.44
| Professional | | $870.96 | $1,000.00 | $1,445.44 |
- 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
- $1,047.13 / $1,047.13 / $1,380.38
| Professional | | $1,047.13 | $1,047.13 | $1,380.38 |
- 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
- $724.44 / $1,380.38 / $1,698.24
| Professional | | $724.44 | $1,380.38 | $1,698.24 |
- 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 / $1,096.48 / $1,778.28
| Professional | | $870.96 | $1,096.48 | $1,778.28 |