- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,089.30 / $5,011.87
| Facility | | $1,047.13 | $2,089.30 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $676.08 / $1,047.13
| Professional | | $295.12 | $676.08 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $12,022.64 / $14,454.40
| Facility | | $7,413.10 | $12,022.64 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,445.44 / $2,089.30
| Professional | | $724.44 | $1,445.44 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $1,288.25 / $2,041.74
| Facility | | $199.53 | $1,288.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $549.54 / $891.25
| Professional | | $398.11 | $549.54 | $891.25 |