- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $6,025.60 / $7,943.28
| Facility | | $1,819.70 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $12,302.69 / $12,302.69
| Facility | | $12,302.69 | $12,302.69 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,089.30 / $4,570.88
| Professional | | $1,096.48 | $2,089.30 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,570.40 / $25,118.86
| Facility | | $1,148.15 | $2,570.40 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,691.53 / $3,162.28
| Professional | | $2,089.30 | $2,691.53 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $12,302.69 / $12,302.69
| Facility | | $12,302.69 | $12,302.69 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $11,748.98 / $28,183.83
| Facility | | $4,677.35 | $11,748.98 | $28,183.83 |