- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $6,918.31 / $10,964.78
| Facility | | $4,168.69 | $6,918.31 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $363.08 / $1,000.00
| Professional | | $234.42 | $363.08 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $446.68 / $977.24
| Professional | | $257.04 | $446.68 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $478.63 / $660.69
| Professional | | $346.74 | $478.63 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,964.78 / $16,595.87
| Facility | | $6,606.93 | $10,964.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $436.52 / $1,318.26
| Professional | | $204.17 | $436.52 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,606.93 / $10,964.78
| Facility | | $2,951.21 | $6,606.93 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $363.08 / $851.14
| Professional | | $213.80 | $363.08 | $851.14 |