- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,511.38 / $13,489.63
| Facility | | $4,570.88 | $8,511.38 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $794.33 / $1,000.00
| Professional | | $489.78 | $794.33 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $17,378.01 / $31,622.78
| Facility | | $8,912.51 | $17,378.01 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $758.58 / $891.25
| Professional | | $316.23 | $758.58 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $13,489.63 / $19,498.45
| Facility | | $5,888.44 | $13,489.63 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,148.15 / $2,398.83
| Professional | | $616.60 | $1,148.15 | $2,398.83 |