- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $5,011.87 / $8,511.38
| Facility | | $436.52 | $5,011.87 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $5,495.41 / $6,760.83
| Professional | | $436.52 | $5,495.41 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,202.26 / $1,445.44
| Professional | | $1,047.13 | $1,202.26 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,489.63 / $13,489.63 / $16,595.87
| Professional | | $13,489.63 | $13,489.63 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $741.31 / $16,218.10
| Facility | | $436.52 | $741.31 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $1,000.00 / $1,949.84
| Professional | | $398.11 | $1,000.00 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $1,548.82 / $10,964.78
| Professional | | $398.11 | $1,548.82 | $10,964.78 |