- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $4,570.88 / $11,220.18
| Facility | | $1,047.13 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $1,905.46
| Professional | | $776.25 | $1,000.00 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $6,606.93 / $14,791.08
| Facility | | $2,238.72 | $6,606.93 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,148.15 / $2,238.72
| Professional | | $758.58 | $1,148.15 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,041.74 / $6,165.95
| Facility | | $398.11 | $2,041.74 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,380.38 / $2,630.27
| Professional | | $812.83 | $1,380.38 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $2,041.74 / $4,897.79
| Facility | | $691.83 | $2,041.74 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,148.15 / $2,041.74
| Professional | | $794.33 | $1,148.15 | $2,041.74 |