- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.55 / $215.20 / $338.54
| Professional | | $113.55 | $215.20 | $338.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.21 / $2,542.48 / $5,974.25
| Facility | | $461.21 | $2,542.48 | $5,974.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.43 / $356.31 / $356.31
| Professional | | $257.43 | $356.31 | $356.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.91 / $325.27 / $475.02
| Professional | | $249.91 | $325.27 | $475.02 |