- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $4,073.80 / $4,897.79
| Facility | | $1,659.59 | $4,073.80 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $1,230.27 / $1,905.46
| Professional | | $363.08 | $1,230.27 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $501.19 / $501.19
| Professional | | $95.50 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $645.65 / $2,454.71
| Professional | | $346.74 | $645.65 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $4,570.88 / $5,128.61
| Facility | | $1,659.59 | $4,570.88 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $1,659.59 / $2,344.23
| Professional | | $407.38 | $1,659.59 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $645.65 / $2,454.71
| Professional | | $346.74 | $645.65 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,754.40 / $9,120.11
| Facility | | $2,454.71 | $5,754.40 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $1,288.25 / $2,754.23
| Professional | | $436.52 | $1,288.25 | $2,754.23 |