- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,128.61 / $8,709.64
| Facility | | $1,202.26 | $5,128.61 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $630.96 / $741.31
| Professional | | $223.87 | $630.96 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,125.38 / $20,417.38 / $38,904.51
| Facility | | $14,125.38 | $20,417.38 | $38,904.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,000.00 / $1,584.89
| Professional | | $724.44 | $1,000.00 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $3,548.13
| Professional | | $1,202.26 | $1,202.26 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Professional | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $6,760.83 / $9,549.93
| Facility | | $2,630.27 | $6,760.83 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $870.96 / $1,513.56
| Professional | | $630.96 | $870.96 | $1,513.56 |