- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $10,964.78 / $16,595.87
| Facility | | $1,698.24 | $10,964.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $812.83 / $3,162.28
| Professional | | $575.44 | $812.83 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Professional | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $891.25 / $4,466.84
| Facility | | $676.08 | $891.25 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,698.24 / $3,890.45
| Professional | | $1,318.26 | $1,698.24 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,290.87 / $3,467.37
| Professional | | $2,238.72 | $2,290.87 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,162.28 / $4,570.88
| Facility | | $891.25 | $3,162.28 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $602.56 / $2,089.30
| Professional | | $60.26 | $602.56 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $2,511.89 / $3,801.89
| Professional | | $831.76 | $2,511.89 | $3,801.89 |