- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $12,022.64 / $16,595.87
| Facility | | $9,772.37 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,905.46 / $2,630.27
| Professional | | $1,000.00 | $1,905.46 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $2,398.83 / $3,715.35
| Facility | | $457.09 | $2,398.83 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,949.84 / $2,691.53
| Professional | | $691.83 | $1,949.84 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $8,128.31 / $10,715.19
| Professional | | $3,630.78 | $8,128.31 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $1,995.26 / $3,715.35
| Facility | | $363.08 | $1,995.26 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $9,332.54 / $12,022.64
| Professional | | $794.33 | $9,332.54 | $12,022.64 |