- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,398.83 / $9,772.37
| Facility | | $2,089.30 | $2,398.83 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $588.84 / $1,659.59
| Professional | | $426.58 | $588.84 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $9,772.37 / $15,488.17
| Facility | | $1,698.24 | $9,772.37 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $954.99 / $1,348.96
| Professional | | $524.81 | $954.99 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $891.25 / $1,698.24
| Professional | | $316.23 | $891.25 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $954.99 / $1,621.81
| Professional | | $588.84 | $954.99 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $954.99 / $1,737.80
| Professional | | $645.65 | $954.99 | $1,737.80 |