- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $6,606.93 / $16,595.87
| Facility | | $2,238.72 | $6,606.93 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $891.25 / $2,238.72
| Professional | | $660.69 | $891.25 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,454.71 / $3,162.28
| Professional | | $1,905.46 | $2,454.71 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $5,248.07
| Facility | | $645.65 | $2,344.23 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,511.89 / $3,715.35
| Professional | | $1,621.81 | $2,511.89 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,019.95 / $4,168.69
| Professional | | $2,290.87 | $3,019.95 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $933.25 / $5,248.07
| Facility | | $645.65 | $933.25 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $977.24 / $2,454.71
| Professional | | $60.26 | $977.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $3,388.44 / $4,265.80
| Professional | | $776.25 | $3,388.44 | $4,265.80 |