- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $10,964.78 / $16,595.87
| Facility | | $2,041.74 | $10,964.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $776.25 / $3,630.78
| Professional | | $602.56 | $776.25 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $5,128.61
| Facility | | $741.31 | $1,047.13 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,995.26 / $4,570.88
| Professional | | $1,548.82 | $1,995.26 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,801.89
| Professional | | $2,691.53 | $2,691.53 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,630.78 / $5,248.07
| Facility | | $1,047.13 | $3,630.78 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $630.96 / $2,238.72
| Professional | | $60.26 | $630.96 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,778.28 / $5,248.07
| Professional | | $1,698.24 | $1,778.28 | $5,248.07 |