- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $5,623.41 / $13,489.63
| Facility | | $1,230.27 | $5,623.41 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $851.14 / $1,949.84
| Professional | | $691.83 | $851.14 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $10,232.93 / $20,892.96
| Facility | | $3,801.89 | $10,232.93 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,071.52 / $1,995.26
| Professional | | $676.08 | $1,071.52 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $5,011.87 / $16,982.44
| Facility | | $1,348.96 | $5,011.87 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,202.26 / $2,570.40
| Professional | | $776.25 | $1,202.26 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $8,912.51 / $20,417.38
| Facility | | $3,019.95 | $8,912.51 | $20,417.38 |
- 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 |