- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $1,543.03 / $3,955.04
| Facility | | $1,518.41 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.55 / $1,142.95 / $13,531.45
| Professional | | $547.55 | $1,142.95 | $13,531.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,418.01 / $9,442.60 / $11,134.41
| Facility | | $8,418.01 | $9,442.60 | $11,134.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.71 / $768.32 / $1,355.86
| Professional | | $201.71 | $768.32 | $1,355.86 |