- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,570.88 / $8,511.38
| Facility | | $2,290.87 | $4,570.88 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $645.65 / $1,318.26
| Professional | | $524.81 | $645.65 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,168.69 / $12,022.64
| Facility | | $3,630.78 | $4,168.69 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,047.13 / $1,318.26
| Professional | | $537.03 | $1,047.13 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $912.01 / $1,445.44
| Professional | | $660.69 | $912.01 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $977.24
| Professional | | $912.01 | $912.01 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $4,570.88 / $9,332.54
| Facility | | $1,905.46 | $4,570.88 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $741.31 / $1,621.81
| Professional | | $524.81 | $741.31 | $1,621.81 |