- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $512.86 / $3,981.07
| Professional | | $234.42 | $512.86 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $1,258.93 / $3,311.31
| Professional | | $239.88 | $1,258.93 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $1,174.90
| Facility | | $676.08 | $676.08 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $691.83 / $6,456.54
| Professional | | $251.19 | $691.83 | $6,456.54 |
- 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
- $251.19 / $537.03 / $4,897.79
| Professional | | $251.19 | $537.03 | $4,897.79 |