- 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
- $831.76 / $1,000.00 / $2,398.83
| Professional | | $831.76 | $1,000.00 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,318.26 / $3,090.30
| Professional | | $630.96 | $1,318.26 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,174.90 / $1,548.82
| Professional | | $870.96 | $1,174.90 | $1,548.82 |
- 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
- $741.31 / $1,071.52 / $2,344.23
| Professional | | $741.31 | $1,071.52 | $2,344.23 |
- 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
- $457.09 / $870.96 / $1,819.70
| Professional | | $457.09 | $870.96 | $1,819.70 |