- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,137.96 / $7,762.47
| Facility | | $1,202.26 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,202.26 / $1,412.54
| Professional | | $660.69 | $1,202.26 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $630.96 / $2,691.53
| Professional | | $295.12 | $630.96 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,288.25 / $2,454.71
| Professional | | $812.83 | $1,288.25 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $16,218.10
| Facility | | $645.65 | $2,344.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,348.96 / $2,754.23
| Professional | | $912.01 | $1,348.96 | $2,754.23 |