- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,290.87 / $4,073.80
| Facility | | $758.58 | $2,290.87 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,202.26 / $2,454.71
| Professional | | $1,000.00 | $1,202.26 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $6,606.93 / $9,772.37
| Facility | | $2,187.76 | $6,606.93 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $2,691.53
| Professional | | $1,230.27 | $1,737.80 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,412.54 / $2,454.71
| Professional | | $1,071.52 | $1,412.54 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,387.21 / $22,387.21 / $28,840.32
| Facility | | $22,387.21 | $22,387.21 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,317.64 / $9,772.37 / $9,772.37
| Professional | | $8,317.64 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,754.40 / $10,232.93
| Facility | | $3,235.94 | $5,754.40 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,318.26 / $2,238.72
| Professional | | $954.99 | $1,318.26 | $2,238.72 |