- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,388.44 / $6,025.60
| Facility | | $1,737.80 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $2,951.21
| Professional | | $1,202.26 | $1,445.44 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,737.80 / $2,818.38
| Professional | | $676.08 | $1,737.80 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $2,884.03
| Professional | | $32.36 | $33.11 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,187.76 / $2,884.03
| Professional | | $1,737.80 | $2,187.76 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,454.71 / $3,388.44
| Professional | | $1,202.26 | $2,454.71 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,949.84 / $2,754.23
| Professional | | $1,513.56 | $1,949.84 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,128.61 / $13,803.84
| Facility | | $2,290.87 | $5,128.61 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,479.11 / $2,344.23
| Professional | | $1,174.90 | $1,479.11 | $2,344.23 |