- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,570.88 / $8,511.38
| Facility | | $2,290.87 | $4,570.88 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $524.81 / $1,000.00
| Professional | | $407.38 | $524.81 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,365.16 / $10,964.78
| Facility | | $3,715.35 | $4,365.16 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $870.96 / $1,047.13
| Professional | | $398.11 | $870.96 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $741.31 / $1,202.26
| Professional | | $537.03 | $741.31 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $831.76
| Professional | | $741.31 | $741.31 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $7,079.46 / $11,220.18
| Facility | | $4,570.88 | $7,079.46 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $602.56 / $1,202.26
| Professional | | $426.58 | $602.56 | $1,202.26 |