- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $3,548.13 / $4,570.88
| Facility | | $1,412.54 | $3,548.13 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $977.24 / $5,011.87
| Professional | | $354.81 | $977.24 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $630.96 / $6,456.54
| Professional | | $457.09 | $630.96 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $912.01 / $5,754.40
| Professional | | $380.19 | $912.01 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $2,754.23 / $5,495.41
| Professional | | $933.25 | $2,754.23 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $13,489.63 / $41,686.94
| Facility | | $4,897.79 | $13,489.63 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $1,122.02 / $4,786.30
| Professional | | $371.54 | $1,122.02 | $4,786.30 |