- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,467.37 / $4,897.79
| Facility | | $1,380.38 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,000.00 / $1,584.89
| Professional | | $891.25 | $1,000.00 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,589.25 / $30,199.52 / $43,651.58
| Facility | | $12,589.25 | $30,199.52 | $43,651.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,174.90 / $1,905.46
| Professional | | $912.01 | $1,174.90 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $977.24 / $1,096.48
| Facility | | $891.25 | $977.24 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,230.27 / $1,995.26
| Professional | | $954.99 | $1,230.27 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $11,220.18 / $17,378.01
| Facility | | $5,011.87 | $11,220.18 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,047.13 / $1,819.70
| Professional | | $794.33 | $1,047.13 | $1,819.70 |