- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,495.41 / $9,549.93
| Facility | | $3,162.28 | $5,495.41 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $776.25 / $1,479.11
| Professional | | $602.56 | $776.25 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $17,378.01 / $36,307.81
| Facility | | $9,120.11 | $17,378.01 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,318.26 / $1,621.81
| Professional | | $630.96 | $1,318.26 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,071.52 / $1,778.28
| Professional | | $758.58 | $1,071.52 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,230.27
| Professional | | $1,071.52 | $1,071.52 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $10,964.78 / $17,782.79
| Facility | | $6,760.83 | $10,964.78 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $812.83 / $1,737.80
| Professional | | $616.60 | $812.83 | $1,737.80 |