- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $5,495.41 / $7,762.47
| Facility | | $1,071.52 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $933.25 / $2,187.76
| Professional | | $794.33 | $933.25 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $3,630.78 / $7,943.28
| Professional | | $870.96 | $3,630.78 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $977.24 / $2,398.83
| Professional | | $758.58 | $977.24 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $891.25 / $1,949.84
| Professional | | $758.58 | $891.25 | $1,949.84 |
- 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
- $616.60 / $851.14 / $2,290.87
| Professional | | $616.60 | $851.14 | $2,290.87 |