- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,454.71 / $6,456.54
| Facility | | $891.25 | $2,454.71 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,949.84 / $2,398.83
| Professional | | $1,000.00 | $1,949.84 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $7,943.28 / $13,489.63
| Facility | | $3,630.78 | $7,943.28 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,995.26 / $3,090.30
| Professional | | $1,479.11 | $1,995.26 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43,651.58 / $43,651.58 / $43,651.58
| Facility | | $43,651.58 | $43,651.58 | $43,651.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38,904.51 / $46,773.51 / $46,773.51
| Professional | | $38,904.51 | $46,773.51 | $46,773.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $10,232.93 / $19,952.62
| Facility | | $6,456.54 | $10,232.93 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $3,090.30
| Professional | | $1,258.93 | $1,819.70 | $3,090.30 |