- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,897.79 / $11,481.54
| Facility | | $1,202.26 | $4,897.79 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $812.83 / $1,995.26
| Professional | | $660.69 | $812.83 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $10,471.29 / $19,498.45
| Facility | | $3,890.45 | $10,471.29 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,047.13 / $1,905.46
| Professional | | $707.95 | $1,047.13 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $2,344.23 / $6,606.93
| Facility | | $323.59 | $2,344.23 | $6,606.93 |
- 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
- $1,905.46 / $5,248.07 / $12,302.69
| Facility | | $1,905.46 | $5,248.07 | $12,302.69 |
- 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 |