- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,715.35 / $9,549.93
| Facility | | $1,096.48 | $3,715.35 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $2,187.76
| Professional | | $812.83 | $1,000.00 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $6,309.57 / $14,125.38
| Facility | | $2,344.23 | $6,309.57 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,174.90 / $2,187.76
| Professional | | $758.58 | $1,174.90 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,511.89 / $6,309.57
| Facility | | $1,202.26 | $2,511.89 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,348.96 / $2,884.03
| Professional | | $831.76 | $1,348.96 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,754.40 / $13,489.63
| Facility | | $1,995.26 | $5,754.40 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,096.48 / $1,995.26
| Professional | | $758.58 | $1,096.48 | $1,995.26 |