- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,073.80 / $7,762.47
| Facility | | $1,122.02 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $954.99 / $1,905.46
| Professional | | $676.08 | $954.99 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $2,818.38 / $7,943.28
| Professional | | $794.33 | $2,818.38 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $831.76 / $2,454.71
| Professional | | $676.08 | $831.76 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $954.99 / $1,995.26
| Professional | | $812.83 | $954.99 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $16,218.10 / $26,915.35
| Facility | | $3,311.31 | $16,218.10 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $812.83 / $2,187.76
| Professional | | $549.54 | $812.83 | $2,187.76 |