- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,623.41 / $12,302.69
| Facility | | $2,754.23 | $5,623.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $251.19 / $295.12
| Professional | | $199.53 | $251.19 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $1,000.00 / $4,897.79
| Facility | | $239.88 | $1,000.00 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $346.74 / $588.84
| Professional | | $275.42 | $346.74 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,445.44 / $5,623.41
| Facility | | $912.01 | $1,445.44 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $338.84 / $467.74
| Professional | | $275.42 | $338.84 | $467.74 |