- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,715.35 / $9,549.93
| Facility | | $1,047.13 | $3,715.35 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $794.33 / $1,905.46
| Professional | | $676.08 | $794.33 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,888.44 / $13,489.63
| Facility | | $2,290.87 | $5,888.44 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,000.00 / $1,905.46
| Professional | | $660.69 | $1,000.00 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,737.80 / $5,623.41
| Facility | | $851.14 | $1,737.80 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,122.02 / $2,398.83
| Professional | | $741.31 | $1,122.02 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,918.31 / $15,488.17
| Facility | | $2,398.83 | $6,918.31 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $891.25 / $1,698.24
| Professional | | $616.60 | $891.25 | $1,698.24 |