- 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
- $794.33 / $933.25 / $3,467.37
| Professional | | $794.33 | $933.25 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,258.93 / $2,884.03
| Professional | | $870.96 | $1,258.93 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,122.02 / $1,548.82
| Professional | | $851.14 | $1,122.02 | $1,548.82 |
- 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
- $831.76 / $1,230.27 / $3,630.78
| Professional | | $831.76 | $1,230.27 | $3,630.78 |
- 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
- $724.44 / $1,000.00 / $2,238.72
| Professional | | $724.44 | $1,000.00 | $2,238.72 |