- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,466.84 / $8,511.38
| Facility | | $1,778.28 | $4,466.84 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,995.26 / $3,162.28
| Professional | | $1,318.26 | $1,995.26 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $954.99 / $3,467.37
| Professional | | $218.78 | $954.99 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $1,819.70
| Professional | | $1,819.70 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Professional | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,818.38 / $10,232.93
| Facility | | $1,288.25 | $2,818.38 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,388.44 / $14,791.08
| Professional | | $2,290.87 | $3,388.44 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,818.38 / $5,248.07
| Facility | | $1,819.70 | $2,818.38 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,162.28 / $5,011.87
| Professional | | $2,290.87 | $3,162.28 | $5,011.87 |