- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,294.38 / $3,387.06 / $5,651.88
| Facility | | $2,294.38 | $3,387.06 | $5,651.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.41 / $294.62 / $714.83
| Professional | | $120.41 | $294.62 | $714.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.80 / $403.80 / $1,023.96
| Professional | | $178.80 | $403.80 | $1,023.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $355.87 / $1,243.22
| Professional | | $150.00 | $355.87 | $1,243.22 |
- 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
- $588.79 / $784.67 / $1,093.57
| Professional | | $588.79 | $784.67 | $1,093.57 |