- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,754.40 / $9,120.11
| Facility | | $3,235.94 | $5,754.40 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $724.44 / $2,511.89
| Professional | | $602.56 | $724.44 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $3,548.13
| Facility | | $741.31 | $741.31 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $2,398.83
| Professional | | $741.31 | $741.31 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $2,754.23 / $2,951.21
| Facility | | $741.31 | $2,754.23 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Professional | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $2,041.74 / $3,548.13
| Facility | | $588.84 | $2,041.74 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $1,479.11 / $2,238.72
| Professional | | $446.68 | $1,479.11 | $2,238.72 |