- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.67 / $515.05 / $1,360.05
| Professional | | $218.67 | $515.05 | $1,360.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.75 / $708.58 / $1,668.39
| Professional | | $425.75 | $708.58 | $1,668.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.85 / $909.30 / $2,670.51
| Professional | | $270.85 | $909.30 | $2,670.51 |
- 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
- $1,018.11 / $1,447.38 / $2,759.48
| Professional | | $1,018.11 | $1,447.38 | $2,759.48 |