- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,388.44 / $6,025.60
| Facility | | $1,698.24 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,380.38 / $2,884.03
| Professional | | $1,148.15 | $1,380.38 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,698.24 / $2,818.38
| Professional | | $676.08 | $1,698.24 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $2,818.38
| Professional | | $32.36 | $33.11 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,187.76 / $3,630.78
| Professional | | $1,698.24 | $2,187.76 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,398.83 / $3,311.31
| Professional | | $1,174.90 | $2,398.83 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,949.84 / $2,884.03
| Professional | | $1,479.11 | $1,949.84 | $2,884.03 |
- 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
- $1,148.15 / $1,445.44 / $2,290.87
| Professional | | $1,148.15 | $1,445.44 | $2,290.87 |