- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $8,511.38
| Facility | | $912.01 | $912.01 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $912.01 / $2,290.87
| Professional | | $831.76 | $912.01 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,995.26 / $2,398.83
| Professional | | $1,621.81 | $1,995.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $2,818.38
| Professional | | $1,230.27 | $1,737.80 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,412.54 / $2,691.53
| Facility | | $912.01 | $1,412.54 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,621.81 / $7,079.46
| Professional | | $954.99 | $1,621.81 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $12,022.64 / $14,125.38
| Facility | | $10,715.19 | $12,022.64 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,621.81 / $2,187.76
| Professional | | $977.24 | $1,621.81 | $2,187.76 |