- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $10,964.78 / $16,595.87
| Facility | | $2,137.96 | $10,964.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $912.01 / $2,137.96
| Professional | | $645.65 | $912.01 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,344.23 / $3,090.30
| Professional | | $1,737.80 | $2,344.23 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,513.56 / $4,897.79
| Facility | | $645.65 | $1,513.56 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,454.71 / $3,715.35
| Professional | | $1,698.24 | $2,454.71 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,951.21 / $4,168.69
| Professional | | $2,290.87 | $2,951.21 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,380.38 / $3,890.45
| Facility | | $676.08 | $1,380.38 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $977.24 / $2,344.23
| Professional | | $60.26 | $977.24 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $2,884.03 / $4,168.69
| Professional | | $851.14 | $2,884.03 | $4,168.69 |