- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,079.46 / $12,882.50
| Facility | | $4,365.16 | $7,079.46 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,047.13 / $2,884.03
| Professional | | $812.83 | $1,047.13 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $12,302.69 / $13,803.84
| Facility | | $7,413.10 | $12,302.69 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,819.70 / $2,570.40
| Professional | | $851.14 | $1,819.70 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Facility | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,659.59 / $2,511.89
| Professional | | $1,071.52 | $1,659.59 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,547.09 / $24,547.09 / $24,547.09
| Facility | | $24,547.09 | $24,547.09 | $24,547.09 |
- 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 / $1,348.96 / $2,454.71
| Professional | | $812.83 | $1,348.96 | $2,454.71 |