- 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
- $154.88 / $2,344.23 / $6,456.54
| Professional | | $154.88 | $2,344.23 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $912.01 / $3,801.89
| Professional | | $154.88 | $912.01 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $371.54 / $6,606.93
| Professional | | $151.36 | $371.54 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $2,570.40 / $5,623.41
| Professional | | $190.55 | $2,570.40 | $5,623.41 |