- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,819.70 / $2,511.89
| Facility | | $977.24 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $831.76 / $1,174.90
| Professional | | $724.44 | $831.76 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,387.21 / $22,387.21 / $30,199.52
| Facility | | $22,387.21 | $22,387.21 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $1,148.15
| Professional | | $851.14 | $851.14 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,022.64 / $12,022.64 / $12,022.64
| Facility | | $12,022.64 | $12,022.64 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,148.15 / $1,380.38
| Professional | | $676.08 | $1,148.15 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $7,762.47 / $22,908.68
| Facility | | $2,884.03 | $7,762.47 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $977.24 / $1,479.11
| Professional | | $724.44 | $977.24 | $1,479.11 |