- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $4,365.16
| Facility | | $933.25 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,238.72 / $3,630.78
| Professional | | $1,862.09 | $2,238.72 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $28,840.32 / $39,810.72
| Facility | | $16,595.87 | $28,840.32 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,691.53 / $3,311.31
| Professional | | $2,187.76 | $2,691.53 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $1,778.28
| Facility | | $39.81 | $39.81 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $398.11
| Facility | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,884.03 / $3,981.07
| Professional | | $1,778.28 | $2,884.03 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,248.07 / $12,589.25
| Facility | | $1,202.26 | $5,248.07 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $4,265.80
| Professional | | $1,778.28 | $2,344.23 | $4,265.80 |