- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $7,244.36 / $22,908.68
| Facility | | $870.96 | $7,244.36 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $10,232.93
| Professional | | $676.08 | $676.08 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $13,803.84 / $30,199.52
| Facility | | $6,918.31 | $13,803.84 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,803.84 / $13,803.84 / $18,620.87
| Professional | | $13,803.84 | $13,803.84 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,122.02 / $22,908.68
| Facility | | $676.08 | $1,122.02 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $10,232.93
| Professional | | $676.08 | $676.08 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,952.62 / $25,118.86 / $37,153.52
| Facility | | $19,952.62 | $25,118.86 | $37,153.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,022.64 / $18,620.87 / $29,512.09
| Professional | | $12,022.64 | $18,620.87 | $29,512.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,022.64 / $63,095.73 / $77,624.71
| Facility | | $12,022.64 | $63,095.73 | $77,624.71 |