- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $10,964.78 / $16,595.87
| Facility | | $1,949.84 | $10,964.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $776.25 / $3,235.94
| Professional | | $645.65 | $776.25 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Professional | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $891.25 / $4,466.84
| Facility | | $602.56 | $891.25 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,905.46 / $4,466.84
| Professional | | $1,479.11 | $1,905.46 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,981.07
| Professional | | $2,691.53 | $2,691.53 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,235.94 / $4,570.88
| Facility | | $891.25 | $3,235.94 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $645.65 / $2,187.76
| Professional | | $60.26 | $645.65 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,630.27
| Professional | | $1,737.80 | $1,737.80 | $2,630.27 |