- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,549.93 / $12,589.25
| Facility | | $4,570.88 | $9,549.93 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $3,388.44 / $9,549.93
| Professional | | $758.58 | $3,388.44 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $17,378.01 / $31,622.78
| Facility | | $8,912.51 | $17,378.01 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $5,888.44 / $15,488.17
| Professional | | $1,348.96 | $5,888.44 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,137.96 / $14,791.08
| Professional | | $1,202.26 | $2,137.96 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $11,481.54
| Professional | | $10,715.19 | $10,715.19 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $12,589.25 / $21,877.62
| Facility | | $8,912.51 | $12,589.25 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,995.26 / $14,125.38
| Professional | | $794.33 | $1,995.26 | $14,125.38 |