- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,495.41 / $9,549.93
| Facility | | $3,162.28 | $5,495.41 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $977.24 / $2,691.53
| Professional | | $812.83 | $977.24 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $17,378.01 / $26,915.35
| Facility | | $8,912.51 | $17,378.01 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,778.28 / $2,454.71
| Professional | | $851.14 | $1,778.28 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $9,549.93
| Facility | | $851.14 | $851.14 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,778.28 / $2,511.89
| Professional | | $1,096.48 | $1,778.28 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,348.96 / $1,778.28
| Professional | | $870.96 | $1,348.96 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $10,964.78 / $18,620.87
| Facility | | $7,244.36 | $10,964.78 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,445.44 / $2,454.71
| Professional | | $812.83 | $1,445.44 | $2,454.71 |