- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,388.44 / $5,623.41
| Facility | | $2,691.53 | $3,388.44 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $4,073.80
| Professional | | $3,162.28 | $3,162.28 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $1,047.13 / $4,265.80
| Facility | | $56.23 | $1,047.13 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $43,651.58 / $43,651.58
| Professional | | $724.44 | $43,651.58 | $43,651.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $3,630.78 / $9,772.37
| Facility | | $83.18 | $3,630.78 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $2,454.71 / $4,677.35
| Facility | | $295.12 | $2,454.71 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $1,047.13 / $4,265.80
| Facility | | $56.23 | $1,047.13 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $43,651.58 / $43,651.58
| Professional | | $724.44 | $43,651.58 | $43,651.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,754.23 / $4,677.35
| Facility | | $794.33 | $2,754.23 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $9,549.93 / $9,772.37
| Professional | | $9,549.93 | $9,549.93 | $9,772.37 |