- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $19,054.61 / $19,054.61
| Facility | | $2,238.72 | $19,054.61 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $2,238.72 / $7,244.36
| Professional | | $275.42 | $2,238.72 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $676.08 / $1,698.24
| Facility | | $363.08 | $676.08 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $977.24 / $977.24
| Professional | | $645.65 | $977.24 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $1,737.80 / $10,232.93
| Facility | | $363.08 | $1,737.80 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $3,235.94 / $8,912.51
| Professional | | $851.14 | $3,235.94 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,862.09 / $3,467.37
| Facility | | $602.56 | $1,862.09 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $218.78
| Professional | | $218.78 | $218.78 | $218.78 |