- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $863.55 / $6,825.52 / $13,413.92
| Facility | | $863.55 | $6,825.52 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.32 / $1,123.91 / $1,658.61
| Professional | | $219.32 | $1,123.91 | $1,658.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $678.73 / $678.73 / $981.34
| Professional | | $678.73 | $678.73 | $981.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $244.51 / $1,573.47 / $2,322.05
| Facility | | $244.51 | $1,573.47 | $2,322.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $493.28 / $1,281.00 / $1,990.18
| Professional | | $493.28 | $1,281.00 | $1,990.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.50 / $1,146.25 / $1,720.06
| Professional | | $823.50 | $1,146.25 | $1,720.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $244.51 / $1,573.47 / $2,322.05
| Facility | | $244.51 | $1,573.47 | $2,322.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.33 / $1,166.25 / $2,004.75
| Professional | | $421.33 | $1,166.25 | $2,004.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,240.48 / $3,240.48 / $3,240.48
| Facility | | $3,240.48 | $3,240.48 | $3,240.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.28 / $1,177.61 / $1,785.44
| Professional | | $776.28 | $1,177.61 | $1,785.44 |