- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $10,964.78 / $16,595.87
| Facility | | $1,202.26 | $10,964.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $512.86 / $1,202.26
| Professional | | $346.74 | $512.86 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,288.25 / $1,778.28
| Professional | | $977.24 | $1,288.25 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $630.96 / $2,754.23
| Facility | | $380.19 | $630.96 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,412.54 / $2,137.96
| Professional | | $1,000.00 | $1,412.54 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $2,290.87
| Professional | | $1,288.25 | $1,698.24 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $562.34 / $2,137.96
| Facility | | $380.19 | $562.34 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $549.54 / $1,288.25
| Professional | | $60.26 | $549.54 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $1,778.28 / $2,290.87
| Professional | | $446.68 | $1,778.28 | $2,290.87 |