- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,248.07 / $12,022.64
| Facility | | $1,148.15 | $5,248.07 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $851.14 / $1,778.28
| Professional | | $691.83 | $851.14 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $8,511.38 / $17,782.79
| Facility | | $3,311.31 | $8,511.38 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,047.13 / $1,949.84
| Professional | | $676.08 | $1,047.13 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,949.84 / $5,754.40
| Facility | | $398.11 | $1,949.84 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,202.26 / $2,570.40
| Professional | | $758.58 | $1,202.26 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,162.28 / $10,232.93
| Facility | | $851.14 | $3,162.28 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,000.00 / $1,819.70
| Professional | | $707.95 | $1,000.00 | $1,819.70 |