- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,981.07 / $4,168.69
| Facility | | $2,089.30 | $3,981.07 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $562.34 / $4,365.16
| Professional | | $263.03 | $562.34 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $1,412.54 / $3,715.35
| Professional | | $263.03 | $1,412.54 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,174.90 / $1,174.90
| Facility | | $676.08 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $794.33 / $6,606.93
| Professional | | $281.84 | $794.33 | $6,606.93 |
- 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
- $281.84 / $602.56 / $5,011.87
| Professional | | $281.84 | $602.56 | $5,011.87 |