- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,467.37 / $4,897.79
| Facility | | $1,148.15 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $812.83 / $1,380.38
| Professional | | $676.08 | $812.83 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $25,118.86 / $31,622.78
| Facility | | $10,471.29 | $25,118.86 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $870.96 / $1,380.38
| Professional | | $660.69 | $870.96 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $707.95 / $812.83
| Facility | | $691.83 | $707.95 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $891.25 / $1,513.56
| Professional | | $691.83 | $891.25 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $812.83 / $1,258.93
| Professional | | $602.56 | $812.83 | $1,258.93 |