- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,089.30 / $5,011.87
| Facility | | $758.58 | $2,089.30 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $575.44 / $741.31
| Professional | | $223.87 | $575.44 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $12,022.64 / $14,454.40
| Facility | | $7,413.10 | $12,022.64 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $616.60 / $1,023.29
| Professional | | $457.09 | $616.60 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,570.40 / $6,606.93
| Facility | | $1,071.52 | $2,570.40 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $794.33 / $1,174.90
| Professional | | $549.54 | $794.33 | $1,174.90 |