- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $5,623.41 / $9,549.93
| Facility | | $691.83 | $5,623.41 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $5,011.87 / $7,762.47
| Professional | | $691.83 | $5,011.87 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,995.26 / $12,589.25
| Professional | | $1,479.11 | $1,995.26 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $7,413.10 / $16,218.10
| Professional | | $1,122.02 | $7,413.10 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,089.30 / $10,715.19
| Facility | | $758.58 | $2,089.30 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $11,481.54 / $14,125.38
| Professional | | $1,174.90 | $11,481.54 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,782.79 / $19,952.62 / $19,952.62
| Facility | | $17,782.79 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,041.74 / $14,454.40
| Professional | | $891.25 | $2,041.74 | $14,454.40 |