- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,677.35 / $16,595.87
| Facility | | $2,187.76 | $4,677.35 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $954.99 / $1,348.96
| Professional | | $177.83 | $954.99 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $2,630.27
| Professional | | $602.56 | $602.56 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $977.24 / $5,888.44
| Facility | | $204.17 | $977.24 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $1,202.26 / $5,011.87
| Professional | | $380.19 | $1,202.26 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,148.15 / $4,365.16
| Professional | | $691.83 | $1,148.15 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $1,380.38 / $5,888.44
| Facility | | $257.04 | $1,380.38 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $239.88 / $2,630.27
| Professional | | $60.26 | $239.88 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $1,122.02 / $3,162.28
| Professional | | $239.88 | $1,122.02 | $3,162.28 |