- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.84 / $251.67 / $2,194.63
| Professional | | $150.84 | $251.67 | $2,194.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.54 / $1,041.53 / $3,050.17
| Professional | | $245.54 | $1,041.53 | $3,050.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.08 / $485.55 / $5,645.15
| Professional | | $180.08 | $485.55 | $5,645.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $4,086.00 / $9,622.00
| Facility | | $3,146.00 | $4,086.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,863.25 / $3,913.02 / $5,631.03
| Professional | | $1,863.25 | $3,913.02 | $5,631.03 |