- 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
- $208.93 / $323.59 / $602.56
| Professional | | $208.93 | $323.59 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $380.19 / $562.34
| Professional | | $223.87 | $380.19 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,570.40 / $2,570.40
| Facility | | $1,318.26 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $436.52 / $812.83
| Professional | | $229.09 | $436.52 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $3,548.13 / $7,413.10
| Facility | | $831.76 | $3,548.13 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $331.13 / $616.60
| Professional | | $204.17 | $331.13 | $616.60 |