- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,248.07 / $12,589.25
| Facility | | $1,202.26 | $5,248.07 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $851.14 / $1,862.09
| Professional | | $707.95 | $851.14 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $9,120.11 / $17,378.01
| Facility | | $3,388.44 | $9,120.11 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,122.02 / $2,041.74
| Professional | | $724.44 | $1,122.02 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,698.24 / $5,888.44
| Facility | | $398.11 | $1,698.24 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,202.26 / $2,570.40
| Professional | | $794.33 | $1,202.26 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $9,120.11 / $20,892.96
| Facility | | $2,884.03 | $9,120.11 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $954.99 / $1,778.28
| Professional | | $691.83 | $954.99 | $1,778.28 |