- 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
- $123.71 / $288.61 / $2,673.95
| Professional | | $123.71 | $288.61 | $2,673.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.53 / $391.99 / $3,514.66
| Professional | | $231.53 | $391.99 | $3,514.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.58 / $508.31 / $4,035.22
| Professional | | $147.58 | $508.31 | $4,035.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,596.00 / $7,457.00 / $12,945.00
| Facility | | $4,596.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,351.31 / $2,732.74 / $4,237.10
| Professional | | $2,351.31 | $2,732.74 | $4,237.10 |