- 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
- $132.75 / $297.73 / $968.93
| Professional | | $132.75 | $297.73 | $968.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.37 / $401.77 / $1,272.25
| Professional | | $240.37 | $401.77 | $1,272.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.08 / $525.63 / $1,875.58
| Professional | | $141.08 | $525.63 | $1,875.58 |
- 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
- $677.66 / $1,078.16 / $1,849.76
| Professional | | $677.66 | $1,078.16 | $1,849.76 |