- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $4,073.80 / $6,456.54
| Facility | | $1,096.48 | $4,073.80 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $977.24 / $2,754.23
| Professional | | $380.19 | $977.24 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $3,235.94 / $7,079.46
| Professional | | $380.19 | $3,235.94 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $851.14 / $1,949.84
| Professional | | $346.74 | $851.14 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,819.70 / $1,905.46
| Professional | | $758.58 | $1,819.70 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $12,882.50 / $26,915.35
| Facility | | $3,311.31 | $12,882.50 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $851.14 / $2,238.72
| Professional | | $316.23 | $851.14 | $2,238.72 |