- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,897.79 / $11,220.18
| Facility | | $1,122.02 | $4,897.79 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $794.33 / $1,698.24
| Professional | | $707.95 | $794.33 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $28,183.83 / $39,810.72
| Facility | | $4,168.69 | $28,183.83 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,000.00 / $1,621.81
| Professional | | $707.95 | $1,000.00 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $776.25 / $891.25
| Facility | | $707.95 | $776.25 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $5,623.41
| Facility | | $4,677.35 | $4,677.35 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $1,659.59
| Professional | | $776.25 | $1,000.00 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $7,762.47 / $10,964.78
| Facility | | $4,073.80 | $7,762.47 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $831.76 / $1,445.44
| Professional | | $630.96 | $831.76 | $1,445.44 |