- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.53 / $873.34 / $940.53
| Professional | | $670.53 | $873.34 | $940.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $1,755.04 / $1,755.04
| Professional | | $0.02 | $1,755.04 | $1,755.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.15 / $1,041.58 / $1,888.91
| Professional | | $864.15 | $1,041.58 | $1,888.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $714.03 / $1,178.10 / $1,747.92
| Professional | | $714.03 | $1,178.10 | $1,747.92 |