- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $645.65 / $1,230.27
| Professional | | $218.78 | $645.65 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $562.34 / $1,174.90
| Professional | | $223.87 | $562.34 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $2,137.96 / $2,137.96
| Facility | | $676.08 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $562.34 / $1,584.89
| Professional | | $251.19 | $562.34 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,398.83 / $5,495.41
| Facility | | $794.33 | $2,398.83 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $588.84 / $1,230.27
| Professional | | $229.09 | $588.84 | $1,230.27 |