- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $7,762.47 / $10,232.93
| Facility | | $2,137.96 | $7,762.47 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $8,709.64 / $10,232.93
| Professional | | $794.33 | $8,709.64 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $12,589.25 / $17,378.01
| Professional | | $776.25 | $12,589.25 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $22,387.21
| Professional | | $1,621.81 | $1,621.81 | $22,387.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $25,703.96 / $91,201.08
| Facility | | $9,120.11 | $25,703.96 | $91,201.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $954.99 / $20,417.38
| Professional | | $478.63 | $954.99 | $20,417.38 |