- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.75 / $288.35 / $4,234.89
| Professional | | $125.75 | $288.35 | $4,234.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.24 / $703.83 / $2,236.26
| Professional | | $170.24 | $703.83 | $2,236.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.01 / $336.45 / $4,039.51
| Professional | | $172.01 | $336.45 | $4,039.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,917.08 / $3,212.94 / $4,669.04
| Professional | | $1,917.08 | $3,212.94 | $4,669.04 |