- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $381.12 / $3,038.00 / $4,648.82
| Facility | | $381.12 | $3,038.00 | $4,648.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.25 / $1,098.09 / $1,747.66
| Professional | | $231.25 | $1,098.09 | $1,747.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.64 / $607.37 / $2,306.16
| Professional | | $292.64 | $607.37 | $2,306.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.57 / $1,005.37 / $1,316.63
| Professional | | $810.57 | $1,005.37 | $1,316.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.34 / $1,588.30 / $2,783.43
| Professional | | $331.34 | $1,588.30 | $2,783.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,556.00 / $4,495.00
| Facility | | $1,078.00 | $1,556.00 | $4,495.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.94 / $1,395.20 / $2,291.40
| Professional | | $1,152.94 | $1,395.20 | $2,291.40 |