- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $7,762.47 / $13,489.63
| Facility | | $1,122.02 | $7,762.47 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $977.24 / $3,019.95
| Professional | | $588.84 | $977.24 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,096.48 / $2,398.83
| Professional | | $616.60 | $1,096.48 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,288.25 / $1,778.28
| Professional | | $912.01 | $1,288.25 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,791.08 / $22,908.68 / $36,307.81
| Facility | | $14,791.08 | $22,908.68 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $1,096.48 / $3,311.31
| Professional | | $501.19 | $1,096.48 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $7,762.47 / $15,135.61
| Facility | | $3,630.78 | $7,762.47 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $891.25 / $2,041.74
| Professional | | $524.81 | $891.25 | $2,041.74 |