- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $10,964.78 / $16,595.87
| Facility | | $1,548.82 | $10,964.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $645.65 / $2,454.71
| Professional | | $575.44 | $645.65 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $812.83 / $3,467.37
| Facility | | $588.84 | $812.83 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $3,548.13
| Professional | | $1,230.27 | $1,584.89 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $3,090.30
| Professional | | $2,187.76 | $2,187.76 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,454.71 / $3,548.13
| Facility | | $812.83 | $2,454.71 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $501.19 / $1,698.24
| Professional | | $60.26 | $501.19 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,348.96 / $3,090.30
| Professional | | $1,318.26 | $1,348.96 | $3,090.30 |