- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $6,606.93 / $16,595.87
| Facility | | $1,659.59 | $6,606.93 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $741.31 / $1,659.59
| Professional | | $354.81 | $741.31 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,862.09 / $2,398.83
| Professional | | $1,380.38 | $1,862.09 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $1,318.26 / $3,801.89
| Facility | | $524.81 | $1,318.26 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,778.28 / $3,235.94
| Professional | | $1,380.38 | $1,778.28 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,344.23 / $3,235.94
| Professional | | $1,862.09 | $2,344.23 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $1,096.48 / $3,715.35
| Facility | | $524.81 | $1,096.48 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $812.83 / $1,862.09
| Professional | | $60.26 | $812.83 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $1,513.56 / $3,715.35
| Professional | | $549.54 | $1,513.56 | $3,715.35 |