- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,238.72
| Facility | | $870.96 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $912.01 / $2,951.21
| Professional | | $147.91 | $912.01 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $1,698.24
| Facility | | $1,047.13 | $1,230.27 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $2,089.30 / $3,630.78
| Professional | | $147.91 | $2,089.30 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $338.84 / $4,786.30
| Professional | | $141.25 | $338.84 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,951.21 / $4,897.79
| Facility | | $812.83 | $2,951.21 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $1,288.25 / $4,073.80
| Professional | | $120.23 | $1,288.25 | $4,073.80 |