- 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 / $1,202.26 / $1,949.84
| Professional | | $1,000.00 | $1,202.26 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $6,456.54 / $9,772.37
| Facility | | $2,454.71 | $6,456.54 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,348.96 / $2,454.71
| Professional | | $977.24 | $1,348.96 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,288.25 / $1,949.84
| Professional | | $831.76 | $1,288.25 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $45,708.82
| Facility | | $16,595.87 | $16,595.87 | $45,708.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $9,120.11 / $9,120.11
| Professional | | $7,585.78 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,630.78 / $6,309.57
| Facility | | $2,041.74 | $3,630.78 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,230.27 / $2,089.30
| Professional | | $831.76 | $1,230.27 | $2,089.30 |