- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,041.74 / $4,570.88
| Facility | | $758.58 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $2,137.96
| Professional | | $1,000.00 | $1,258.93 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $8,511.38 / $12,022.64
| Facility | | $4,677.35 | $8,511.38 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $1,737.80
| Professional | | $1,202.26 | $1,445.44 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Facility | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,288.25 / $1,819.70
| Professional | | $794.33 | $1,288.25 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,248.07 / $11,748.98
| Facility | | $1,148.15 | $5,248.07 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,202.26 / $1,862.09
| Professional | | $933.25 | $1,202.26 | $1,862.09 |