- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,897.79 / $4,897.79
| Facility | | $1,380.38 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,862.09 / $2,398.83
| Professional | | $1,230.27 | $1,862.09 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $40,738.03 / $57,543.99
| Facility | | $16,982.44 | $40,738.03 | $57,543.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,000.00 / $1,548.82
| Professional | | $575.44 | $1,000.00 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $114,815.36 / $186,208.71
| Facility | | $7,762.47 | $114,815.36 | $186,208.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,584.89
| Professional | | $1,318.26 | $1,318.26 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,412.54 / $2,818.38
| Professional | | $977.24 | $1,412.54 | $2,818.38 |