- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,514.81 / $3,937.50 / $4,600.62
| Facility | | $2,514.81 | $3,937.50 | $4,600.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.61 / $557.86 / $2,504.33
| Professional | | $301.61 | $557.86 | $2,504.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.98 / $1,209.28 / $2,631.37
| Professional | | $300.98 | $1,209.28 | $2,631.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.46 / $574.35 / $4,040.02
| Professional | | $253.46 | $574.35 | $4,040.02 |
- 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
- $1,784.83 / $2,762.52 / $4,358.45
| Professional | | $1,784.83 | $2,762.52 | $4,358.45 |