- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,309.57 / $9,549.93
| Facility | | $4,570.88 | $6,309.57 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $660.69 / $7,244.36
| Professional | | $616.60 | $660.69 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $17,378.01 / $31,622.78
| Facility | | $8,912.51 | $17,378.01 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $1,230.27 / $1,621.81
| Professional | | $467.74 | $1,230.27 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,988.33 / $23,988.33 / $23,988.33
| Professional | | $23,988.33 | $23,988.33 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $12,589.25 / $21,877.62
| Facility | | $8,912.51 | $12,589.25 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $1,513.56 / $24,547.09
| Professional | | $524.81 | $1,513.56 | $24,547.09 |