- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,630.78 / $4,570.88
| Facility | | $1,023.29 | $3,630.78 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $467.74 / $1,288.25
| Professional | | $229.09 | $467.74 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $257.04 / $1,380.38
| Professional | | $218.78 | $257.04 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $741.31 / $2,454.71
| Professional | | $229.09 | $741.31 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $1,047.13 / $1,949.84
| Professional | | $524.81 | $1,047.13 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $5,248.07 / $26,302.68
| Facility | | $812.83 | $5,248.07 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $602.56 / $1,513.56
| Professional | | $213.80 | $602.56 | $1,513.56 |