- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.52 / $923.38 / $945.19
| Professional | | $648.52 | $923.38 | $945.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.16 / $994.30 / $1,626.02
| Professional | | $845.16 | $994.30 | $1,626.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,152.75 / $1,706.09
| Professional | | $300.00 | $1,152.75 | $1,706.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $7,228.00 / $12,680.00
| Facility | | $3,599.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.54 / $1,167.81 / $2,022.91
| Professional | | $730.54 | $1,167.81 | $2,022.91 |