- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,065.28 / $1,786.87 / $4,298.57
| Facility | | $1,065.28 | $1,786.87 | $4,298.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.80 / $554.60 / $2,152.00
| Professional | | $185.80 | $554.60 | $2,152.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $918.84 / $1,575.44 / $3,384.70
| Facility | | $918.84 | $1,575.44 | $3,384.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.42 / $554.60 / $1,864.76
| Professional | | $172.42 | $554.60 | $1,864.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.15 / $478.60 / $1,289.30
| Facility | | $184.15 | $478.60 | $1,289.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.00 / $3,174.88 / $3,174.88
| Professional | | $952.00 | $3,174.88 | $3,174.88 |