- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,398.83 / $9,772.37
| Facility | | $1,737.80 | $2,398.83 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $549.54 / $1,412.54
| Professional | | $407.38 | $549.54 | $1,412.54 |
- 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
- $478.63 / $977.24 / $1,380.38
| Professional | | $478.63 | $977.24 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,000.00 / $1,548.82
| Professional | | $389.05 | $1,000.00 | $1,548.82 |
- 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
- $537.03 / $870.96 / $1,479.11
| Professional | | $537.03 | $870.96 | $1,479.11 |
- 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
- $549.54 / $870.96 / $1,698.24
| Professional | | $549.54 | $870.96 | $1,698.24 |