- 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
- $162.58 / $249.46 / $2,008.79
| Professional | | $162.58 | $249.46 | $2,008.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.93 / $676.80 / $2,573.84
| Professional | | $319.93 | $676.80 | $2,573.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.39 / $404.02 / $3,865.43
| Professional | | $215.39 | $404.02 | $3,865.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.40 / $1,622.32 / $3,495.76
| Professional | | $219.40 | $1,622.32 | $3,495.76 |