- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.13 / $844.91 / $902.35
| Professional | | $597.13 | $844.91 | $902.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $716.41 / $842.84 / $1,494.74
| Professional | | $716.41 | $842.84 | $1,494.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $1,101.88 / $1,586.30
| Professional | | $250.00 | $1,101.88 | $1,586.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.46 / $989.38 / $1,697.75
| Professional | | $581.46 | $989.38 | $1,697.75 |