- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,890.45 / $7,762.47
| Facility | | $2,041.74 | $3,890.45 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $630.96 / $1,819.70
| Professional | | $524.81 | $630.96 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $2,041.74 / $3,019.95
| Facility | | $630.96 | $2,041.74 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $870.96 / $1,621.81
| Professional | | $741.31 | $870.96 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $707.95 / $1,202.26
| Professional | | $501.19 | $707.95 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $812.83 / $9,332.54
| Facility | | $575.44 | $812.83 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $707.95 / $4,677.35
| Professional | | $489.78 | $707.95 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,079.46 / $10,964.78
| Facility | | $5,495.41 | $7,079.46 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $602.56 / $1,122.02
| Professional | | $467.74 | $602.56 | $1,122.02 |