- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $3,715.35 / $5,011.87
| Facility | | $812.83 | $3,715.35 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,890.45 / $5,888.44
| Professional | | $3,388.44 | $3,890.45 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $25,703.96 / $35,481.34
| Facility | | $10,232.93 | $25,703.96 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,265.80 / $6,606.93
| Professional | | $3,019.95 | $4,265.80 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,548.13 / $3,715.35
| Facility | | $3,162.28 | $3,548.13 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,495.41 / $7,079.46
| Facility | | $3,467.37 | $5,495.41 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,265.80 / $9,549.93
| Professional | | $3,311.31 | $4,265.80 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,365.16 / $7,244.36
| Professional | | $3,162.28 | $4,365.16 | $7,244.36 |