- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,456.54 / $13,803.84
| Facility | | $3,630.78 | $6,456.54 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $1,096.48
| Professional | | $794.33 | $794.33 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $2,511.89 / $7,244.36
| Facility | | $316.23 | $2,511.89 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $1,230.27 / $3,162.28
| Professional | | $416.87 | $1,230.27 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $6,165.95 / $14,125.38
| Facility | | $2,884.03 | $6,165.95 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $831.76 / $2,089.30
| Professional | | $208.93 | $831.76 | $2,089.30 |