- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,388.44 / $14,791.08
| Facility | | $2,398.83 | $3,388.44 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $891.25 / $2,238.72
| Professional | | $602.56 | $891.25 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,623.41 / $8,912.51
| Facility | | $5,011.87 | $5,623.41 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,548.82 / $2,187.76
| Professional | | $724.44 | $1,548.82 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $1,548.82 / $2,454.71
| Professional | | $549.54 | $1,548.82 | $2,454.71 |
- 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
- $831.76 / $1,318.26 / $2,290.87
| Professional | | $831.76 | $1,318.26 | $2,290.87 |
- 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
- $891.25 / $1,380.38 / $2,691.53
| Professional | | $891.25 | $1,380.38 | $2,691.53 |