- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,570.88 / $8,511.38
| Facility | | $2,290.87 | $4,570.88 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $676.08 / $3,467.37
| Professional | | $169.82 | $676.08 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $1,778.28 / $3,890.45
| Professional | | $295.12 | $1,778.28 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $645.65 / $4,677.35
| Professional | | $275.42 | $645.65 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $3,548.13
| Professional | | $2,754.23 | $2,754.23 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,890.45 / $6,760.83
| Facility | | $1,288.25 | $3,890.45 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $977.24 / $4,265.80
| Professional | | $194.98 | $977.24 | $4,265.80 |