- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $9,549.93 / $16,595.87
| Facility | | $1,479.11 | $9,549.93 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $616.60 / $2,398.83
| Professional | | $549.54 | $616.60 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $1,584.89
| Professional | | $1,584.89 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $724.44 / $3,311.31
| Facility | | $575.44 | $724.44 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,548.82 / $3,388.44
| Professional | | $1,202.26 | $1,548.82 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,818.38
| Professional | | $2,089.30 | $2,089.30 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $2,398.83 / $3,388.44
| Facility | | $724.44 | $2,398.83 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $467.74 / $1,584.89
| Professional | | $60.26 | $467.74 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,258.93 / $3,162.28
| Professional | | $1,202.26 | $1,258.93 | $3,162.28 |