- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,344.23 / $4,897.79
| Facility | | $831.76 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $870.96 / $1,318.26
| Professional | | $758.58 | $870.96 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,417.38 / $40,738.03 / $52,480.75
| Facility | | $20,417.38 | $40,738.03 | $52,480.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $245.47 / $660.69
| Professional | | $181.97 | $245.47 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $776.25 / $831.76
| Facility | | $707.95 | $776.25 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $954.99 / $1,584.89
| Professional | | $741.31 | $954.99 | $1,584.89 |
- 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
- $707.95 / $1,000.00 / $1,621.81
| Professional | | $707.95 | $1,000.00 | $1,621.81 |