- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,213.54 / $2,778.87 / $5,394.10
| Facility | | $2,213.54 | $2,778.87 | $5,394.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.35 / $313.33 / $719.36
| Professional | | $124.35 | $313.33 | $719.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.16 / $408.08 / $802.56
| Professional | | $190.16 | $408.08 | $802.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $378.57 / $1,256.00
| Professional | | $150.00 | $378.57 | $1,256.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $594.29 / $870.62 / $1,213.05
| Professional | | $594.29 | $870.62 | $1,213.05 |