- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $10,964.78 / $16,595.87
| Facility | | $1,513.56 | $10,964.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $616.60 / $2,691.53
| Professional | | $524.81 | $616.60 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Professional | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $794.33 / $3,801.89
| Facility | | $549.54 | $794.33 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,659.59 / $3,467.37
| Professional | | $1,288.25 | $1,659.59 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,951.21
| Professional | | $2,137.96 | $2,137.96 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,691.53 / $3,801.89
| Facility | | $794.33 | $2,691.53 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $489.78 / $1,659.59
| Professional | | $60.26 | $489.78 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,995.26 / $3,388.44
| Professional | | $1,318.26 | $1,995.26 | $3,388.44 |