- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $4,897.79 / $10,471.29
| Facility | | $1,348.96 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $870.96 / $1,862.09
| Professional | | $676.08 | $870.96 | $1,862.09 |
- 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
- $691.83 / $1,348.96 / $1,737.80
| Professional | | $691.83 | $1,348.96 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $1,862.09
| Professional | | $812.83 | $1,148.15 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,288.25
| Professional | | $1,148.15 | $1,148.15 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $7,079.46 / $11,220.18
| Facility | | $4,570.88 | $7,079.46 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $954.99 / $2,089.30
| Professional | | $676.08 | $954.99 | $2,089.30 |