- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $3,801.89 / $8,511.38
| Facility | | $741.31 | $3,801.89 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,025.60 / $11,748.98
| Facility | | $4,570.88 | $6,025.60 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $13,803.84 / $13,803.84
| Facility | | $13,803.84 | $13,803.84 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $4,073.80 / $8,709.64
| Facility | | $436.52 | $4,073.80 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $6,309.57 / $11,220.18
| Professional | | $691.83 | $6,309.57 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $13,803.84 / $13,803.84
| Facility | | $13,803.84 | $13,803.84 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $8,912.51 / $23,442.29
| Facility | | $6,309.57 | $8,912.51 | $23,442.29 |