- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $15,848.93
| Facility | | $2,398.83 | $3,235.94 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $977.24 / $1,778.28
| Professional | | $794.33 | $977.24 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,677.35 / $6,309.57
| Facility | | $3,467.37 | $4,677.35 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,698.24 / $2,344.23
| Professional | | $794.33 | $1,698.24 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,584.89 / $2,630.27
| Professional | | $1,047.13 | $1,584.89 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,380.38 / $2,089.30
| Professional | | $933.25 | $1,380.38 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,380.38 / $2,398.83
| Professional | | $933.25 | $1,380.38 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $1,047.13
| Facility | | $660.69 | $660.69 | $1,047.13 |