- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $416.87 / $2,344.23
| Professional | | $173.78 | $416.87 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $524.81 / $2,570.40
| Professional | | $295.12 | $524.81 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $457.09 / $3,981.07
| Professional | | $213.80 | $457.09 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $13,489.63
| Facility | | $3,715.35 | $7,762.47 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $416.87 / $2,754.23
| Professional | | $177.83 | $416.87 | $2,754.23 |