- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $5,128.61 / $7,762.47
| Facility | | $1,122.02 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $954.99 / $2,238.72
| Professional | | $794.33 | $954.99 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $2,884.03 / $7,079.46
| Professional | | $812.83 | $2,884.03 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $954.99 / $2,454.71
| Professional | | $776.25 | $954.99 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $933.25 / $1,995.26
| Professional | | $812.83 | $933.25 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $16,218.10 / $26,302.68
| Facility | | $2,344.23 | $16,218.10 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $891.25 / $2,398.83
| Professional | | $630.96 | $891.25 | $2,398.83 |