- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $5,495.41 / $10,715.19
| Facility | | $2,041.74 | $5,495.41 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $5,011.87 / $5,495.41
| Professional | | $1,288.25 | $5,011.87 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $25,703.96 / $56,234.13
| Facility | | $15,848.93 | $25,703.96 | $56,234.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $7,413.10 / $10,715.19
| Professional | | $5,623.41 | $7,413.10 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $9,332.54
| Professional | | $9,332.54 | $9,332.54 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $8,912.51 / $8,912.51
| Professional | | $660.69 | $8,912.51 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,489.63 / $19,054.61 / $32,359.37
| Facility | | $13,489.63 | $19,054.61 | $32,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,584.89 / $4,365.16
| Professional | | $1,000.00 | $1,584.89 | $4,365.16 |