- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,365.16 / $10,964.78
| Facility | | $1,122.02 | $4,365.16 | $10,964.78 |
- 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
- $2,630.27 / $7,413.10 / $14,791.08
| Facility | | $2,630.27 | $7,413.10 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,071.52 / $2,041.74
| Professional | | $741.31 | $1,071.52 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,344.23 / $6,918.31
| Facility | | $1,348.96 | $2,344.23 | $6,918.31 |
- 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
- $1,698.24 / $5,370.32 / $12,022.64
| Facility | | $1,698.24 | $5,370.32 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,000.00 / $1,862.09
| Professional | | $707.95 | $1,000.00 | $1,862.09 |