- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $1,949.84
| Facility | | $1,548.82 | $1,819.70 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $47.86 / $2,511.89
| Professional | | $30.20 | $47.86 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,621.81 / $2,570.40
| Professional | | $1,023.29 | $1,621.81 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $12,589.25 / $12,589.25
| Professional | | $5,888.44 | $12,589.25 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $54.95 / $85.11
| Professional | | $39.81 | $54.95 | $85.11 |