- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,238.72 / $3,235.94
| Facility | | $2,089.30 | $2,238.72 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,995.26 / $2,818.38
| Professional | | $1,023.29 | $1,995.26 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $645.65 / $1,659.59
| Facility | | $363.08 | $645.65 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $1,949.84 / $10,232.93
| Facility | | $562.34 | $1,949.84 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,862.09 / $3,715.35
| Facility | | $616.60 | $1,862.09 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.70 / $53.70 / $53.70
| Professional | | $53.70 | $53.70 | $53.70 |