- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $7,413.10 / $17,378.01
| Facility | | $1,513.56 | $7,413.10 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,230.27 / $13,182.57
| Professional | | $776.25 | $1,230.27 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $7,762.47 / $12,302.69
| Facility | | $398.11 | $7,762.47 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $50.12 / $50.12
| Professional | | $50.12 | $50.12 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $5,128.61 / $10,715.19
| Facility | | $676.08 | $5,128.61 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Professional | | $1,148.15 | $1,148.15 | $1,148.15 |