- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,495.41 / $9,549.93
| Facility | | $2,290.87 | $5,495.41 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,071.52 / $2,754.23
| Professional | | $812.83 | $1,071.52 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,548.82 / $1,778.28
| Professional | | $912.01 | $1,548.82 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,630.78 / $6,918.31
| Facility | | $1,548.82 | $3,630.78 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,258.93 / $2,041.74
| Professional | | $812.83 | $1,258.93 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,445.44 / $2,344.23
| Professional | | $812.83 | $1,445.44 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $3,548.13
| Professional | | $812.83 | $1,000.00 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $6,918.31 / $12,022.64
| Facility | | $1,737.80 | $6,918.31 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $1,949.84
| Professional | | $812.83 | $1,148.15 | $1,949.84 |