- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $5,623.41 / $14,125.38
| Facility | | $1,288.25 | $5,623.41 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $870.96 / $1,995.26
| Professional | | $758.58 | $870.96 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $9,120.11 / $16,982.44
| Facility | | $3,548.13 | $9,120.11 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,071.52 / $1,995.26
| Professional | | $724.44 | $1,071.52 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,041.74 / $5,754.40
| Facility | | $398.11 | $2,041.74 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,202.26 / $2,630.27
| Professional | | $758.58 | $1,202.26 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,981.07 / $9,549.93
| Facility | | $1,548.82 | $3,981.07 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,000.00 / $1,819.70
| Professional | | $691.83 | $1,000.00 | $1,819.70 |