- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $2,290.87 / $4,073.80
| Facility | | $575.44 | $2,290.87 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $562.34 / $1,096.48
| Professional | | $467.74 | $562.34 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,187.76 / $2,951.21
| Facility | | $1,258.93 | $2,187.76 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $794.33 / $1,230.27
| Professional | | $562.34 | $794.33 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $707.95 / $1,096.48
| Professional | | $501.19 | $707.95 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $19,498.45
| Facility | | $4,786.30 | $4,786.30 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,677.35 / $4,677.35
| Professional | | $3,890.45 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,290.87 / $4,073.80
| Facility | | $1,202.26 | $2,290.87 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $616.60 / $1,047.13
| Professional | | $457.09 | $616.60 | $1,047.13 |