- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $5,888.44 / $14,454.40
| Facility | | $1,445.44 | $5,888.44 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $1,949.84
| Professional | | $812.83 | $1,000.00 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,311.31 / $6,025.60
| Facility | | $1,230.27 | $3,311.31 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,380.38 / $1,995.26
| Professional | | $851.14 | $1,380.38 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,791.08 / $26,915.35 / $40,738.03
| Facility | | $14,791.08 | $26,915.35 | $40,738.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,445.44 / $2,398.83
| Professional | | $977.24 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,122.02 / $2,511.89
| Professional | | $977.24 | $1,122.02 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,235.94 / $8,128.31
| Facility | | $1,047.13 | $3,235.94 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $2,238.72
| Professional | | $870.96 | $1,230.27 | $2,238.72 |