- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $5,128.61 / $12,589.25
| Facility | | $1,318.26 | $5,128.61 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,230.27 / $2,818.38
| Professional | | $1,000.00 | $1,230.27 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $13,489.63 / $28,840.32
| Facility | | $4,897.79 | $13,489.63 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,548.82 / $2,818.38
| Professional | | $954.99 | $1,548.82 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $3,548.13 / $9,772.37
| Facility | | $398.11 | $3,548.13 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,737.80 / $3,630.78
| Professional | | $1,096.48 | $1,737.80 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $7,244.36 / $16,982.44
| Facility | | $2,511.89 | $7,244.36 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $2,630.27
| Professional | | $1,023.29 | $1,445.44 | $2,630.27 |