- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $7,244.36 / $11,748.98
| Facility | | $4,466.84 | $7,244.36 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $870.96 / $3,090.30
| Professional | | $724.44 | $870.96 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $2,630.27
| Professional | | $812.83 | $1,174.90 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $1,380.38
| Professional | | $776.25 | $1,000.00 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,791.08 / $22,908.68 / $36,307.81
| Facility | | $14,791.08 | $22,908.68 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,122.02 / $3,235.94
| Professional | | $741.31 | $1,122.02 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $7,762.47 / $15,135.61
| Facility | | $3,630.78 | $7,762.47 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $912.01 / $2,089.30
| Professional | | $645.65 | $912.01 | $2,089.30 |