- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $6,165.95 / $16,595.87
| Facility | | $1,513.56 | $6,165.95 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,202.26 / $3,162.28
| Professional | | $1,000.00 | $1,202.26 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $14,125.38 / $30,902.95
| Facility | | $5,370.32 | $14,125.38 | $30,902.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,479.11 / $2,951.21
| Professional | | $977.24 | $1,479.11 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $15,848.93 / $36,307.81
| Facility | | $3,090.30 | $15,848.93 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,737.80 / $3,548.13
| Professional | | $1,122.02 | $1,737.80 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $9,332.54 / $23,988.33
| Facility | | $3,019.95 | $9,332.54 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,380.38 / $2,570.40
| Professional | | $977.24 | $1,380.38 | $2,570.40 |