- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $7,079.46 / $14,125.38
| Facility | | $1,412.54 | $7,079.46 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $512.86 / $1,023.29
| Professional | | $295.12 | $512.86 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,174.90 / $2,187.76
| Professional | | $758.58 | $1,174.90 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $676.08 / $2,570.40
| Facility | | $338.84 | $676.08 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,348.96 / $2,454.71
| Professional | | $776.25 | $1,348.96 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,778.28 / $2,691.53
| Professional | | $1,122.02 | $1,778.28 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $676.08 / $2,187.76
| Facility | | $338.84 | $676.08 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $645.65 / $1,174.90
| Professional | | $60.26 | $645.65 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $1,412.54 / $2,454.71
| Professional | | $457.09 | $1,412.54 | $2,454.71 |