- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $4,897.79 / $13,182.57
| Facility | | $1,412.54 | $4,897.79 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $912.01 / $4,168.69
| Professional | | $309.03 | $912.01 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $2,137.96 / $19,952.62
| Professional | | $323.59 | $2,137.96 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $691.83 / $4,265.80
| Professional | | $281.84 | $691.83 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $3,388.44 / $3,467.37
| Professional | | $602.56 | $3,388.44 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $12,882.50 / $26,915.35
| Facility | | $3,311.31 | $12,882.50 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $812.83 / $4,073.80
| Professional | | $257.04 | $812.83 | $4,073.80 |