- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,064.83 / $2,424.15 / $3,955.04
| Facility | | $2,064.83 | $2,424.15 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.04 / $351.98 / $4,273.78
| Professional | | $153.04 | $351.98 | $4,273.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.04 / $877.45 / $2,283.02
| Professional | | $213.04 | $877.45 | $2,283.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.00 / $419.66 / $4,133.16
| Professional | | $214.00 | $419.66 | $4,133.16 |
- 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
- $1,958.58 / $3,281.34 / $4,855.95
| Professional | | $1,958.58 | $3,281.34 | $4,855.95 |