- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $4,897.79 / $6,918.31
| Facility | | $794.33 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $602.56 / $794.33
| Professional | | $354.81 | $602.56 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $9,772.37
| Facility | | $9,772.37 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,772.37 / $9,772.37
| Professional | | $9,332.54 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,230.27 / $6,918.31
| Facility | | $794.33 | $1,230.27 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $489.78 / $758.58
| Professional | | $416.87 | $489.78 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $8,511.38 / $18,197.01
| Facility | | $3,311.31 | $8,511.38 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $489.78 / $851.14
| Professional | | $380.19 | $489.78 | $851.14 |