- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,890.45 / $7,943.28
| Facility | | $2,041.74 | $3,890.45 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $616.60 / $1,047.13
| Professional | | $173.78 | $616.60 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,995.26 / $2,951.21
| Facility | | $616.60 | $1,995.26 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,019.95 / $9,332.54
| Professional | | $2,884.03 | $3,019.95 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,737.80 / $4,466.84
| Facility | | $724.44 | $1,737.80 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $724.44 / $1,737.80
| Professional | | $436.52 | $724.44 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,290.87 / $5,495.41
| Facility | | $1,348.96 | $2,290.87 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $660.69 / $1,096.48
| Professional | | $416.87 | $660.69 | $1,096.48 |