- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $4,897.79 / $6,918.31
| Facility | | $933.25 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $812.83 / $977.24
| Professional | | $676.08 | $812.83 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,454.71
| Facility | | $2,041.74 | $2,041.74 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $12,022.64 / $12,022.64
| Professional | | $2,454.71 | $12,022.64 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $891.25 / $1,584.89
| Professional | | $524.81 | $891.25 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,041.74 / $6,918.31
| Facility | | $933.25 | $2,041.74 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $812.83 / $977.24
| Professional | | $691.83 | $812.83 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $977.24 / $1,380.38
| Professional | | $676.08 | $977.24 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $10,964.78 / $22,908.68
| Facility | | $5,370.32 | $10,964.78 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $1,258.93
| Professional | | $776.25 | $1,000.00 | $1,258.93 |