- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,312.74 / $5,312.74 / $5,312.74
| Facility | | $5,312.74 | $5,312.74 | $5,312.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.89 / $1,234.58 / $2,436.98
| Professional | | $314.89 | $1,234.58 | $2,436.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.47 / $340.51 / $395.96
| Professional | | $326.47 | $340.51 | $395.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,675.27 / $1,675.27 / $1,675.27
| Facility | | $1,675.27 | $1,675.27 | $1,675.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.44 / $915.38 / $2,667.89
| Professional | | $271.44 | $915.38 | $2,667.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.29 / $1,266.42 / $2,285.59
| Professional | | $736.29 | $1,266.42 | $2,285.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.61 / $1,542.06 / $2,877.40
| Professional | | $1,023.61 | $1,542.06 | $2,877.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.72 / $981.72 / $1,387.38
| Professional | | $981.72 | $981.72 | $1,387.38 |