- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $7,413.10 / $11,748.98
| Facility | | $4,466.84 | $7,413.10 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,096.48 / $3,981.07
| Professional | | $954.99 | $1,096.48 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,445.44 / $3,388.44
| Professional | | $1,000.00 | $1,445.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,230.27 / $1,698.24
| Professional | | $977.24 | $1,230.27 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,302.68 / $42,657.95 / $66,069.34
| Facility | | $26,302.68 | $42,657.95 | $66,069.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,412.54 / $4,265.80
| Professional | | $954.99 | $1,412.54 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,120.11 / $21,379.62
| Facility | | $4,570.88 | $9,120.11 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,096.48 / $2,511.89
| Professional | | $831.76 | $1,096.48 | $2,511.89 |