- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $9,772.37 / $14,125.38
| Facility | | $4,466.84 | $9,772.37 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,122.02 / $3,162.28
| Professional | | $1,000.00 | $1,122.02 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,548.82 / $3,715.35
| Professional | | $707.95 | $1,548.82 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,412.54 / $1,862.09
| Professional | | $1,047.13 | $1,412.54 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,022.64 / $19,054.61 / $30,199.52
| Facility | | $12,022.64 | $19,054.61 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,258.93 / $2,754.23
| Professional | | $891.25 | $1,258.93 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,120.11 / $21,379.62
| Facility | | $4,570.88 | $9,120.11 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $1,047.13 / $2,137.96
| Professional | | $549.54 | $1,047.13 | $2,137.96 |