- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $6,606.93 / $10,964.78
| Facility | | $4,168.69 | $6,606.93 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $1,000.00 / $2,511.89
| Professional | | $316.23 | $1,000.00 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $1,096.48 / $3,090.30
| Professional | | $316.23 | $1,096.48 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $2,511.89 / $3,019.95
| Professional | | $602.56 | $2,511.89 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $10,471.29 / $15,848.93
| Facility | | $6,456.54 | $10,471.29 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $1,380.38 / $2,818.38
| Professional | | $269.15 | $1,380.38 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $7,585.78 / $15,135.61
| Facility | | $3,630.78 | $7,585.78 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $1,230.27 / $2,951.21
| Professional | | $323.59 | $1,230.27 | $2,951.21 |