- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,786.30
| Facility | | $3,981.07 | $3,981.07 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $446.68 / $1,445.44
| Professional | | $251.19 | $446.68 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $354.81 / $645.65
| Professional | | $302.00 | $354.81 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $549.54 / $776.25
| Professional | | $371.54 | $549.54 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $19,498.45 / $67,608.30
| Facility | | $4,466.84 | $19,498.45 | $67,608.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $575.44 / $812.83
| Professional | | $380.19 | $575.44 | $812.83 |