- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,554.21 / $1,554.21 / $1,554.21
| Facility | | $1,554.21 | $1,554.21 | $1,554.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.43 / $296.51 / $573.54
| Facility | | $225.43 | $296.51 | $573.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,174.42 / $3,495.38 / $3,605.29
| Professional | | $3,174.42 | $3,495.38 | $3,605.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,638.02 / $3,992.52 / $4,990.66
| Professional | | $2,638.02 | $3,992.52 | $4,990.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $791.41 / $1,450.91 / $10,442.16
| Facility | | $791.41 | $1,450.91 | $10,442.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.01 / $1,319.01 / $6,353.23
| Professional | | $1,319.01 | $1,319.01 | $6,353.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,638.02 / $3,341.49 / $4,817.88
| Facility | | $2,638.02 | $3,341.49 | $4,817.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,638.02 / $4,326.35 / $5,495.88
| Professional | | $2,638.02 | $4,326.35 | $5,495.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,572.07 / $2,572.07 / $4,484.63
| Professional | | $2,572.07 | $2,572.07 | $4,484.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.06 / $1,319.01 / $4,286.78
| Professional | | $1,253.06 | $1,319.01 | $4,286.78 |