- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,480.90 / $3,243.94 / $3,955.04
| Facility | | $1,480.90 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.90 / $507.42 / $1,609.25
| Professional | | $215.90 | $507.42 | $1,609.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.12 / $690.80 / $2,157.81
| Professional | | $411.12 | $690.80 | $2,157.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.71 / $895.80 / $3,041.15
| Professional | | $255.71 | $895.80 | $3,041.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $4,086.00 / $9,622.00
| Facility | | $3,146.00 | $4,086.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.61 / $1,869.22 / $3,002.47
| Professional | | $1,460.61 | $1,869.22 | $3,002.47 |