- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $12,022.64 / $16,595.87
| Facility | | $1,513.56 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $616.60 / $1,513.56
| Professional | | $478.63 | $616.60 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,698.24 / $2,187.76
| Professional | | $1,258.93 | $1,698.24 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $794.33 / $3,388.44
| Facility | | $478.63 | $794.33 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,621.81 / $2,951.21
| Professional | | $1,258.93 | $1,621.81 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,089.30 / $2,951.21
| Professional | | $1,621.81 | $2,089.30 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $776.25 / $2,691.53
| Facility | | $489.78 | $776.25 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $707.95 / $1,698.24
| Professional | | $60.26 | $707.95 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,348.96 / $3,388.44
| Professional | | $616.60 | $1,348.96 | $3,388.44 |