- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,090.30 / $11,481.54
| Facility | | $2,398.83 | $3,090.30 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $794.33 / $2,290.87
| Professional | | $707.95 | $794.33 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $10,715.19 / $15,848.93
| Facility | | $9,332.54 | $10,715.19 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,659.59 / $2,398.83
| Professional | | $691.83 | $1,659.59 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $1,513.56 / $2,630.27
| Professional | | $234.42 | $1,513.56 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,258.93 / $2,137.96
| Professional | | $776.25 | $1,258.93 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,288.25 / $2,630.27
| Professional | | $831.76 | $1,288.25 | $2,630.27 |