- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $4,897.79 / $10,964.78
| Facility | | $1,047.13 | $4,897.79 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,202.26 / $1,778.28
| Professional | | $977.24 | $1,202.26 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $14,454.40 / $19,498.45
| Facility | | $6,456.54 | $14,454.40 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,071.52 / $1,698.24
| Professional | | $851.14 | $1,071.52 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,000.00 / $1,047.13
| Facility | | $891.25 | $1,000.00 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,412.54 / $2,754.23
| Professional | | $954.99 | $1,412.54 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $7,762.47 / $10,964.78
| Facility | | $2,630.27 | $7,762.47 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,288.25 / $1,995.26
| Professional | | $891.25 | $1,288.25 | $1,995.26 |