- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $8,912.51 / $8,912.51
| Facility | | $1,778.28 | $8,912.51 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $602.56 / $4,677.35
| Professional | | $407.38 | $602.56 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,548.82 / $1,737.80
| Professional | | $1,023.29 | $1,548.82 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $933.25 / $1,659.59
| Professional | | $616.60 | $933.25 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,754.23 / $10,471.29
| Facility | | $2,630.27 | $2,754.23 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $977.24 / $2,089.30
| Professional | | $602.56 | $977.24 | $2,089.30 |