- 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
- $562.34 / $691.83 / $1,412.54
| Professional | | $562.34 | $691.83 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $14,125.38 / $16,595.87
| Facility | | $7,079.46 | $14,125.38 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,122.02 / $1,412.54
| Professional | | $575.44 | $1,122.02 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $977.24 / $1,548.82
| Professional | | $707.95 | $977.24 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $1,047.13
| Professional | | $977.24 | $977.24 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $6,025.60 / $9,332.54
| Facility | | $3,388.44 | $6,025.60 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $794.33 / $1,737.80
| Professional | | $562.34 | $794.33 | $1,737.80 |