- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $12,302.69 / $20,417.38
| Facility | | $1,737.80 | $12,302.69 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $1,000.00 / $2,041.74
| Professional | | $549.54 | $1,000.00 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $912.01 / $1,445.44
| Professional | | $537.03 | $912.01 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,096.48 / $2,187.76
| Professional | | $724.44 | $1,096.48 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $12,022.64
| Facility | | $2,818.38 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $954.99 / $1,995.26
| Professional | | $602.56 | $954.99 | $1,995.26 |