- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,715.35 / $9,772.37
| Facility | | $1,096.48 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $912.01 / $1,995.26
| Professional | | $724.44 | $912.01 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $9,120.11 / $17,782.79
| Facility | | $2,818.38 | $9,120.11 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,047.13 / $1,995.26
| Professional | | $724.44 | $1,047.13 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,344.23 / $5,754.40
| Facility | | $1,230.27 | $2,344.23 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,230.27 / $2,630.27
| Professional | | $776.25 | $1,230.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $7,244.36 / $16,218.10
| Facility | | $2,511.89 | $7,244.36 | $16,218.10 |
- 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 |