- 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
- $645.65 / $776.25 / $2,089.30
| Professional | | $645.65 | $776.25 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $707.95 / $1,148.15
| Professional | | $524.81 | $707.95 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $891.25 / $1,412.54
| Professional | | $89.13 | $891.25 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,511.38 / $43,651.58
| Facility | | $4,466.84 | $8,511.38 | $43,651.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $912.01 / $1,445.44
| Professional | | $602.56 | $912.01 | $1,445.44 |