- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $1,543.03 / $3,955.04
| Facility | | $1,518.41 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.41 / $282.39 / $2,579.17
| Professional | | $98.41 | $282.39 | $2,579.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.74 / $330.50 / $3,162.26
| Professional | | $193.74 | $330.50 | $3,162.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.44 / $340.55 / $4,140.82
| Professional | | $149.44 | $340.55 | $4,140.82 |
- 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
- $2,107.69 / $2,443.26 / $4,096.33
| Professional | | $2,107.69 | $2,443.26 | $4,096.33 |