- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,801.74 / $3,949.00 / $5,043.35
| Facility | | $2,801.74 | $3,949.00 | $5,043.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.26 / $188.38 / $246.72
| Professional | | $153.26 | $188.38 | $246.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.25 / $239.92 / $377.67
| Professional | | $155.25 | $239.92 | $377.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,584.54 / $3,584.54 / $3,584.54
| Facility | | $3,584.54 | $3,584.54 | $3,584.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.37 / $313.20 / $566.84
| Professional | | $221.37 | $313.20 | $566.84 |