- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,344.23 / $4,897.79
| Facility | | $1,047.13 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,122.02 / $1,819.70
| Professional | | $977.24 | $1,122.02 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $17,378.01 / $25,703.96
| Facility | | $8,317.64 | $17,378.01 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,380.38 / $2,137.96
| Professional | | $977.24 | $1,380.38 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,000.00 / $1,071.52
| Facility | | $912.01 | $1,000.00 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,412.54 / $3,019.95
| Professional | | $977.24 | $1,412.54 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,258.93 / $2,041.74
| Professional | | $912.01 | $1,258.93 | $2,041.74 |