- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $5,495.41 / $6,309.57
| Facility | | $1,621.81 | $5,495.41 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $4,466.84
| Professional | | $371.54 | $371.54 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $977.24 / $1,621.81
| Facility | | $104.71 | $977.24 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $977.24 / $1,513.56
| Professional | | $912.01 | $977.24 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $5,495.41 / $7,244.36
| Facility | | $977.24 | $5,495.41 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $4,466.84 / $7,244.36
| Professional | | $371.54 | $4,466.84 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $77.62
| Professional | | $30.20 | $30.20 | $77.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,412.54 / $1,995.26
| Facility | | $1,047.13 | $1,412.54 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,513.56 / $1,584.89
| Professional | | $977.24 | $1,513.56 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,168.69 / $4,466.84
| Facility | | $2,630.27 | $4,168.69 | $4,466.84 |