- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $7,943.28 / $16,595.87
| Facility | | $1,380.38 | $7,943.28 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,202.26 / $2,454.71
| Professional | | $1,000.00 | $1,202.26 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,454.71
| Professional | | $933.25 | $1,318.26 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $2,290.87
| Professional | | $1,023.29 | $1,445.44 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,548.82 / $2,754.23
| Facility | | $1,071.52 | $1,548.82 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $22,387.21 / $33,113.11
| Facility | | $8,317.64 | $22,387.21 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,348.96 / $2,454.71
| Professional | | $977.24 | $1,348.96 | $2,454.71 |